HR Forms

This is the place for human resource and employee benefit forms.

Dental & Vision Documents & Forms

DentalClaimFormRev.pdf View Download	Dental claim form.	39k	v. 6	Aug 5, 2011 7:22 AM	Maroney, Sandy
DentalVisionBenefitsSummaryPlanDescription.pdf View Download	Summary Plan Description for Dental & Vision	593k	v. 5	Aug 8, 2011 8:40 AM	Maroney, Sandy
VisionClaimFormRev.pdf View Download	Vision Claim form.	27k	v. 5	Aug 5, 2011 7:22 AM	Maroney, Sandy
VisionPlusBasic.pdf View Download	Blue Cross 7100 & 128 Plan Vision Benefits	162k	v. 3	Oct 18, 2011 11:04 AM	Maroney, Sandy
VisionPlusEnhanced.pdf View Download	Blue Cross 206 Plan Vision Benefits	32k	v. 3	Oct 18, 2011 11:04 AM	Maroney, Sandy

Direct Deposit

Direct Deposit Authorization.pdf
View Download

Direct Deposit Form for Checking, Savings, and HSA Accounts.

14k

v. 3

May 8, 2012 8:22 AM

Maroney, Sandy

Employee Information Change Form

EmployeeInfo_ChangeForm.pdf
View Download

Employee Information Change Form

16k

v. 3

Jul 29, 2011 10:41 AM

Maroney, Sandy

FSA & HRA Forms

		General+Claim+Form+.pdf View Download	General Claim for FSA, HRA, and Hospitalization Reimbursement	92k	v. 2	Nov 11, 2010 5:04 PM	Wasiewicz, Mark
		IndHlth_FSA_HRA.pdf View Download	Independent Health FSA & HRA Enrollment form.	268k	v. 3	Jul 29, 2011 12:49 PM	Wasiewicz, Mark

FSA & HRA Information

FSA_Dependent_Care_expenses.pdf View Download	Independent Health Dependent Care Expense	109k	v. 4	Aug 8, 2011 8:33 AM	Maroney, Sandy
FSA_-_Give_Yourself_A_Raise.pdf View Download	Employee Tax Savings Example Sheet	49k	v. 3	Aug 8, 2011 8:38 AM	Maroney, Sandy
FSA_Informational_Brochure.pdf View Download	Independent Health Flexible Spending Account Brochure	725k	v. 3	Aug 8, 2011 8:32 AM	Maroney, Sandy
STELFSAHRAInformationSheet.pdf View Download	STEL FSA & HRA Information for Plan Year 12/1/10-11/30/11	55k	v. 4	Aug 8, 2011 8:36 AM	Maroney, Sandy

Lincoln Life Insurance

EnrollmentFormforGroupInsurance.pdf View Download	Lincoln Life Enrollment Form for Group Life Insurance	59k	v. 4	Aug 8, 2011 8:21 AM	Maroney, Sandy
EvidenceofInsurabilityInformation.pdf View Download	Evidence of Insurability Information Form	173k	v. 3	Aug 8, 2011 8:43 AM	Maroney, Sandy
GroupInsuranceChangeRequest.pdf View Download	Lincoln Life Change Request Form	51k	v. 3	Aug 8, 2011 8:40 AM	Maroney, Sandy
LincolnLifeSummaryofBenefits.pdf View Download	Summary of Benefits for Voluntary Life and AD&D	127k	v. 3	Aug 8, 2011 8:41 AM	Maroney, Sandy

Medical Insurance

BlueCrossBlueShieldEnrollmentApplicationChangeForm.pdf
View Download

BC/BS Enrollment Application and Change Form

53k

v. 3

Aug 8, 2011 9:19 AM

Maroney, Sandy

NYS Disability

NYS Workers' Compensation

Open Enrollment

2011-2012OpenEnrollmentPacket.pdf View Download	Open Enrollment Letter Meeting Schedule Benefit Information Plan Summaries Benefit Election Form Premium Plan Salary Reduction Form	887k	v. 3	Oct 6, 2011 12:48 PM	Maroney, Sandy
OpenEnrollmentInformation,FSAandHealthCareSavingsAccts.pdf View Download	Open Enrollment Letter Flexible Spending Account Information and Enrollment Form Health Care Savings Acct & FSA Election Form	631k	v. 5	Oct 6, 2011 12:48 PM	Maroney, Sandy
PremiumAssistanceProgram.pdf View Download		919k	v. 2	Oct 6, 2011 12:48 PM	Maroney, Sandy

Retirement 403(b)

		SalaryReductionAgreement.pdf View Download	Salary reduction agreement for the 403(b) plan.	58k	v. 3	Aug 19, 2011 8:05 AM	Maroney, Sandy
		STEL403(b)PlanSummaryofPlanProvisions.pdf View Download	Summary booklet for the STEL 403(b)Plan.	417k	v. 3	Aug 19, 2011 8:06 AM	Maroney, Sandy

Retirement 403(b)(7) - P&A Retirement Services

Retirement 403(b)(7) - Vanguard

EstablishVanguard403b.pdf View Download	Establish a 403(b)(7) account with Vanguard	417k	v. 3	Aug 8, 2011 9:42 AM	Wasiewicz, Mark
VanguardBeneficiaryDesigForm.pdf View Download	Vanguard 403(b)(7)Beneficiary Designation Form	133k	v. 2	Aug 8, 2011 9:49 AM	Wasiewicz, Mark
VanguardInstallmentDistribution.pdf View Download	Vanguard 403(b)(7) Installment Distribution Form	408k	v. 2	Aug 8, 2011 9:49 AM	Wasiewicz, Mark
VanguardSalaryReduction.pdf View Download	Vanguard Salary Reduction Agreement for 403(b)(7) Custodial Accounts	48k	v. 4	Aug 8, 2011 9:39 AM	Wasiewicz, Mark
VanguardSingleDistribution.pdf View Download	Vanguard Single Distribution Form	691k	v. 4	Aug 8, 2011 9:42 AM	Wasiewicz, Mark

Short Term Disability

ShortTermDisabilityHighlights.pdf View Download	First Unum's Voluntary Short-Term Disability Insurance Highlights	13k	v. 3	Aug 8, 2011 8:25 AM	Maroney, Sandy
ShortTermDisabilityWorksheet.pdf View Download	Unum Monthly Expenses Worksheet	91k	v. 3	Aug 8, 2011 8:29 AM	Maroney, Sandy
ShortTermDisabiltyQuote.pdf View Download	Short Term Disability Quote Sheet	9k	v. 3	Aug 8, 2011 8:30 AM	Maroney, Sandy

Sick Leave Compensation

		SickLeaveCompensationMemo.pdf View Download	Memo regarding use of sick leave credits	304k	v. 3	Aug 8, 2011 8:54 AM	Maroney, Sandy
		STEL207ACertificationofHealthCareProvider.pdf View Download	STEL207A Form to be Completed by Health Care Provider	94k	v. 4	Aug 8, 2011 8:52 AM	Maroney, Sandy

Stellar Benefits Hot Lines

Stellar Benefits Hot Lines_2012.pdf
View Download

18k

v. 2

May 17, 2012 7:45 AM

Maroney, Sandy

Withholding Tax Forms

		Form IT2104 NYS.pdf View Download	2012 Employee's Withholding Allowance Certificate - New York State	513k	v. 3	Feb 13, 2012 12:35 PM	Maroney, Sandy
		FormW-42012.pdf View Download	2012 Employee's Withholding Allowance Certificate - Federal	136k	v. 4	Feb 13, 2012 12:34 PM	Maroney, Sandy

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