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Application for up to $150 annual reimbursement for health club/gym membership. 2014 Benefits Program Enrollment/Change Form (pdf) One form to enroll in most benefit programs for employees working 20+ hours per week. 2013 Health Care Flexible Spending Account Reimbursement Form (pdf) Application for reimbursement of 2013 qualifed medical and dental expenses. Affidavit of Domestic Partnership for Benefits Eligibility (pdf) Required to add your Domestic Partner to coverage. Statement of Termination of Domestic Partnership (pdf) Required to discontinue your Domestic Partner's coverage. Affidavit of Tax Dependent Status (pdf) Required for children over age 19 to determine tax dependent status. Application Form for Personal Computer Loan (pdf) The Institution offers interest-free loans from $300 to $2,500 for the purchase of a personal computer. Application Form for Tuition Loan for Children of Employees (pdf) If you are a regular full-time employee at the Institution, you are eligible for an interest-free loan for the higher education of your children or legal dependents. » Download alternative format - MS Word Child/Dependent Care Expense Reimbursement Form (pdf) Employee/Spouse Work Verification Form (pdf) » Download alternative format - MS Word Dependent Care Subsidy Worksheet (pdf) Use this form to determine how much to deposit into your Dependent Care Assistance Program (DCAP). General2014 Benefits Program Enrollment/Change Form (pdf)One form to enroll in most benefit programs for employees working 20+ hours per week. Affidavit of Domestic Partnership for Benefits Eligibility (pdf) Required to add your Domestic Partner to coverage. Statement of Termination of Domestic Partnership (pdf) Required to discontinue your Domestic Partner's coverage. Employee/Spouse Work Verification Form (pdf) » Download alternative format - MS Word FSA Informational Sheet Health/DentalBCBS-MA Fitness Benefit Reimbursement FormApplication for up to $150 annual reimbursement for health club/gym membership. 2013 Health Care Flexible Spending Account Reimbursement Form (pdf) Application for reimbursement of 2013 qualifed medical and dental expenses. 2014 Health Care Flexible Spending Account (FSA) and Health Reimbursement Account (HRA) Reimbursement Form Health Equity application for reimbursement of qualified expenses from flexible spending accounts or health reimbursement accounts. 2014 Health Savings Account (HSA) Reimbursement Form Health Equity application for reimbursement from HSA accounts. Affidavit of Tax Dependent Status (pdf) Required for children over age 19 to determine tax dependent status. Child/Dependent CareDependent Care Reimbursement FormUse this form to get reimbursed for dependent care services. DC-FSA Worksheet Use this form to determine how much to deposit into your Dependent Care Assistance Program (DCAP). DCS Spouse Work Verification Child/Dependent Care Enrollment Form (pdf) Use this form to enroll in the Dependent Care Reimbursement Plan (DCAP)/Dependent Care Subsidy. Loan ApplicationsEmployee Education AssistanceApplication for employee education tuition reimbursement. Application Form for Personal Computer Loan (pdf) The Institution offers interest-free loans from $300 to $2,500 for the purchase of a personal computer. Application Form for Tuition Loan for Children of Employees (pdf) If you are a regular full-time employee at the Institution, you are eligible for an interest-free loan for the higher education of your children or legal dependents. » Download alternative format - MS Word RetirementBeneficiary Form for 403(b) Defined Contribution Retirement Plan (pdf)Use this form to change beneficiary information for your 403(b) Defined Contribution Retirement Plan with Transamerica. Beneficiary Form for Defined Benefit Retirement Plan (pdf) Use this form to change beneficiary information for your Defined Benefit retirement benefits. » Download alternative format - MS Word Retirement Estimate Request Form (MS Word) Use this form to notify Human Resources of your actual retirement date or to request an estimate of your retirement benefit under the Defined Benefit Plan. Last updated: March 24, 2014 | |||||||||||||
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