Kutztown University HUMAN RESOURCES -- Personnel/Payroll: Benefits Information

Benefits Forms:

Act 34 Clearance (SP 164)	Request for Criminal Record Check
Address Change Form
Alternative Retirement Plan Representatives	For those enrolled in ARP retirement - AIG Valic, Fidelity, ING & TIAA-CREF
Direct Deposit Form	Can have pay direct deposited in up to 2 accounts If checking account, voided check should be included with this form.
Family Medical Leave (FMLA)	Family Medical Leave - Employee Form Family Medical Leave - Family Member Form
Flexible Spending Accounts	Reimbursement Form for Dependent Care Reimbursement Account Reimbursement Form for Medical Reimbursement Account
Highmark Blue Shield Indemnity Plan	NO NEW ENROLLMENTS Plan Updated 07/01/08 (comprehensive major medical) Not for PEBTF
Highmark PPOBlue Benefits Grid PPO Preventive Schedule	Not for PEBTF covered employees
Highmark Blue Shield Claim Form	PASSHE Employee Member Submitted Claim Form - NOT FOR PEBTF
HIPAA NOTICES	PEBTF HIPAA PASSHE Notice of Privacy Practices SEAP HIPAA Notice
Life Insurance (Basic Group) Beneficiary Form	Beneficiary updates for Employer-paid life insurance through Prudential. Submit directly to Prudential.
Long-Term Disability Evidence of Insurability	To be completed for those electing LTD coverage after 31 days of hire date. Complete form and submit to Human Resources for handling.
Long-Term Disability Claim Form	Instructions for filing of LTD claim
PASSHE Benefits Enrollment/Change Form APSCUF, Management, Coaches, OPEIU & SPFPA	To update information for PASSHE employees. Submit to HR Office for processing.
PEBTF-2 Enrollment/Change Form	To update information for PEBTF employees. Submit to HR Office for coding and forwarding to PEBTF. AFSCME & SCUPA
PEBTF Student Certification Form	PEBTF Student Certification Instructions *For first-time or mid-year certification.*
PEBTF January Student Certification Form	PEBTF January Student Certification Instructions Completion of Certification & Verification required in January.
Retirement Plan Information	Comparison of Retirement Plans Guide ARP Company Comparison Guide
Retirement Plan Allocation Change Form - ARP participants only!	If enrolled in the Alternate Retirement Plan, allocation changes between companies can be made twice during a calendar year.
Salary Deferral Agreements 457 vs 403(b) Plan Comparison Tax Sheltered Annuities Plan Limits for 2009	Deferred Compensation Plan Program Details 457(b) Plan - Great West Retirement Services KU Representative: Jaime Robbins - 1-866-737-7457, press 2 ext 62229 jaime.robbins@gwrs.com Informational Sheet Participant Enrollment Form Application for Catch-Up Personal Info. Change Request Tax Deferral of Leave Payments - As a result of the Economic Growth & Tax Relief Reconciliation Act of 2001 (EGTRRA), employees may defer leave payments received upon retirement/termination to the Deferred Compensation Plan (457 Plan) administered by Great West - (Use Salary Deferral Agreement form above.) TSA Salary Reduction form TSA Vendor Listing
TIAA-CREF Retirement Online Enrollment	Select "ENROLL NOW" - USE ACCESS CODE PA100298 To be used for Retirement Annuities only - not TSA's**
Tuition Waivers	For tuition waiver information and related forms
Voluntary Group Life Brochure	Employee-paid additional life insurance with CIGNA.
Voluntary Group Life Enrollment/Change Form	To be used for medical underwriting if coverage exceeds guaranteed amount or if enrolling after 31 days of hire.
W-4 Form - 2009	Update Federal Withholding Information
Workers Comp. Panel	Listing of panel physicians for work-related injuries

Personnel/Payroll
Stratton Administration Center
Room 109

Text Only Version

Benefits Information • Career Development • Employment Opportunities • Payroll Information • Staff Directory • Extras • Home