Kutztown University
Kutztown 			University -- HR

 
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

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