Human Resources / Benefits / Forms

Dental	Disability Insurance
Aetna Dental Claim Form United Concordia Dental Claim Form *Aetna Website* *United Concordia Website*	Medical Evidence of Insurability Form - Short Term and/or Long Term Disability Insurance

Domestic Partner	Family Medical Leave Act (FMLA)*
Domestic Partner Status Declaration Form	FMLA/University Leave of Absence/Return from Leave of Absence Status Form (FOR SUPERVISORY USE ONLY)

Life Insurance	Medical
Beneficiary Change Form Medical Evidence of Insurability Form	Personal Choice Out-of-Network Claim Form Blue Card WorldWide International Claim Form *Independence Blue Cross Website*

Prescription	Retirement / Tax Sheltered Annuity
CareMark Prescription Reimbursement Form CareMark Mail Service Order Form *Caremark Website*	Non-Union Employees, Faculty and Staff Form Non-Tenure Track Faculty Form Employee Voluntary Only Form BUE Salary Reduction Form Police and Security Officers (Local 511) Salary Reduction Form *Fidelity Website* *TIAA-CREF Website*

*As part of the changes to the FMLA, all application/certification forms have been revised. Since the new forms are specific to the condition for which an employee is requesting leave, the Benefits Department will no longer be posting the generic forms on our website. To obtain an application form for an FMLA leave of absence, please submit a request via Self-Service Banner (click here to access SSB via the TUportal) or call the Benefits office at 215-926-2282.