Human Resources

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• Affidavit of Eligible Spouse/Child Status
• Certification of Disabled Dependent Eligibility
• Tobacco-free Affidavit

Insurance Plans
Add or change beneficiaries for IU Basic Life Insurance, Supplemental Life Insurance, and/or Supplemental AD&D:

• Online at the Employee Center (select Benefits).
• Or download and complete a PDF of the Beneficiary Designation Form

Retirement Plans
To change the beneficiaries on your IU retirement plan account(s) contact the company directly.

• Fidelity Investments
• PERF
• TIAA

Health Savings Account (HSA)
Change the beneficiaries on your HSA at Nyhart IU Online Services.

Life Events Changes

• Submit a Life Event Change online
  Make mid-year changes to your medical, dental, flexible spending account, supplemental AD&D, and other due to an IRS-qualifying life event (e.g. marriage, birth of a child).
  • Life Event Instructions

Optional Benefit Changes

• Submit an Optional Benefit Change online
  Make mid-year changes to your health savings account, supplemental retirement plans, supplemental life insurance, and long-term disability elections, or update your beneficiaries, at any time.
  • OBC Instructions

• Statement of Facts Supporting Reasonable Cause of Drug or Alcohol Use by Employee
• Employee Authorization and Consent to Submit to Substance Abuse Testing
• Employee Refusal to Submit To Substance Abuse Testing
• Highlights of a Conditional Employment Agreement
• Request for Alcohol/Drug Screening (campus-specific form and procedures at Office of Insurance, Loss Control & Claims site)

• Authorization Form for Motor Vehicle Records Check (Office of Insurance, Loss Control & Claims)
• Use the eLink option for all background checks. If exceptional circumstances require manual entry, the following form must be reviewed and signed beforehand:
  Background Check Consent Statement
• Conflict of Interest Disclosure Statement
• Employee Referral Incentive Validation Form
• Employee Request/Written Authorization for Release of Personnel Files
• Essential and Marginal Job Functions Worksheet (Word doc)
• I-9 Form and Instructions
• Reasonable Accommodation Request and Documentation Form
• Request for Seasonal Employment of Part-Time Employee (requires IU logon)
• Telephone Reference Check (Bloomington campus)

Part-Time Positions Employment Applications

• Application
• Use the eLink option for all background checks. If exceptional circumstances require manual entry, the following form must be reviewed and signed beforehand:
  Background Check Consent Statement
• Work History Supplement

• Direct Deposit Authorization / Termination Form
• FSA Claim Form
• FSA Dependent Care Worksheet
• Additional Debit Card Request Form
• List of Eligible Merchants for the Healthcare FSA
• Mileage Reimbursement Form
• Nyhart Login Instructions

See the qualified Life Events changes page about making changes to your plan.

Grievance

• Exempt and Non-Exempt Non-Union Staff
• Bloomington and Northwest
  Non-Exempt CWA Staff Employees
• Bloomington, IUPUI, and South Bend:
  Non-Exempt AFSCME Service Employees
• Bloomington, East, IUPUI, Kokomo, Northwest, South Bend, and Southeast
  Non-Exempt AFSCME Police Service Employees
• Part-Time Employees

Staff Report (Bloomington)

This form is being updated.

HIPAA Authorization Form
Give IU Human Resources permission to discuss or disclose your Personal Health Information (PHI) or information related to your benefits to another person.

Dental

• CIGNA Dental Claim Form

Medical

• Anthem Medical Claim Form
• IU Health Center Claim Form (student health insurance only)

Prescription

• Allergy Prescription Reimbursement Claim Form
• Prescription Reimbursement Claim Form
• Prescription Drug Mail Service Order Form

Vision

• Blue View Vision Out-of-Network Claim Form

• HSA Enrollment / Change Form
• HSA Distribution Request Form (request an HSA distribution)
• Additional Debit Card Request Form
• Authorization to Disclose Information Form
• HSA Beneficiary Change / Spousal Consent Form
• HSA Death Distribution Request Form
• HSA Direct Deposit Authorization / Termination Form
• HSA Power of Attorney Form (grant POA over your HSA)
• HSA Transfer Form (transfer your HSA with another vendor to Nyhart)
• Nyhart Login Instructions

Change beneficiaries by logging on to your Nyhart account.

FMLA (Family and Medical Leave Act)

• Certification of Qualifying Exigency for Military Family Leave
• Certification for Serious Injury or Illness of Covered Service Member
• FMLA Definition of Serious Health Conditions
• FMLA Form 1 Leave Notice of Designation, Request, & Approval
• Essential and Marginal Job Functions Worksheet (Word doc)
• FMLA Form 2E Medical Certification for EMPLOYEE
• FMLA Form 2F Medical Certification for FAMILY
• FMLA Form 3 Intent to Return and Fitness for Duty/Medical Release
• Medical Recertification Request
• Tracking Sheet

Leave for Development of Commercial Projects with a Non-University Entity

• Approval for a Leave for Development of Commercial Projects with a Non-University Entity

Leave of Absence

• Leave of Absence (LOA) Request

Military Leaves

• Leaves for Military Families Employee's Request
• Verification of Military Service or Training

Paid Living Donor Leave

• Paid Living Donor Leave Request

Paid Parental Leave

• Paid Parental Leave Request

Basic Life Insurance
Add or change beneficiaries online by submitting an Optional Benefit Change through the Employee Center (select Benefits) or download and complete the PDF.

Long Term Disability (LTD) Insurance

• Claim Packet
• LTD Enrollment/Change/Termination Form
• Medical History Statement to provide Evidence of Insurability:
  • Indiana Residents
    
  • Michigan Residents
  • AR, CO, DC, KY, LA, NJ, NY, OH, PA, TN Residents
  • All Other States Residents

Supplemental Accidental Death & Dismemberment (AD&D)

• Add or change beneficiaries online at the Employee Center (select Benefits) or download and complete the PDF.
• Supplemental AD&D Claim Packet (PDF)

Supplemental Life Insurance

• Add or change beneficiaries online at the Employee Center (select Benefits) or download and complete the PDF.
• Supplemental Life Insurance Enrollment / Change / Termination Form
• Medical History Statement to provide Evidence of Insurability:
  • Indiana Residents
    
  • Michigan Residents
  • AR, CO, DC, KY, LA, NJ, NY, OH, PA, TN Residents
  • All Other States Residents

Supplemental Dependent Life Insurance

• Supplemental Dependent Life Enrollment / Change / Termination Form

Health Information Release

• HIPAA Authorization Form
  Give IU Human Resources permission to discuss or disclose your Personal Health Information (PHI) or information related to your benefits to another person.

Personal Profile Forms

• Change Form, Personal Data
  Update personal information already on file (legal name, marital status, SSN, etc.)
• Personal Profile Form (ED)
  Must be completed by the newly hired employee
• Personal Profile Form (PS)
  For the employee to identify prior work experience, professional education, licenses etc.

Personnel Records Release

• Employee Request/Written Authorization for Release of Personnel Files
  Give IU Human Resources permission to release your campus HR records or department personnel file to another person.

PERF

• See the INPRS web site for PERF forms

Salary Deferral Agreements
Enroll in a supplemental retirement plan or change your contribution amount/type by submitting an Optional Benefit Change through the Employee Center (select Benefits), or by submitting a paper form:

• IU 457(b) Retirement Plan
• IU Tax Deferred Account (TDA)

Beneficiaries
To add or change beneficiaries contact the company(ies) directly:

• Fidelity Investments
• PERF
• TIAA (legacy accounts only)

• Employee Recognition Award Plan
• Employee Referral Incentive Validation Form
• FLSA Status Questionnaire
• Incentive Pay or Commission Plan
• Position Description Form
• Request for Reconsideration of Position Classification (Word doc)

See the Student Health Insurance web pages for forms specific to each plan

• Online IU Tuition Benefit Enrollment Form
  
  Also available as a PDF: 2022-23 PDF Application
• IUHS Tuition Waiver Form

• Service Positions on Bloomington Campus:
  Unsafe Working Conditions (Also available as a Word doc)

• SupportLinc Flyer (PDF)

Dental

• IU Dental Plan
  • Booklet (1/22)
  • Summary (1/23)

Medical Care

• Anthem PPO HDHP
  • Booklet (1/23)
  • Summary (1/23)
  • SBC (1/23)
    
• Anthem PPO $500 Deductible
  • Booklet (1/23)
  • Summary (1/23)
  • SBC (1/23)
    

Prescription Benefit

• Booklet (05/2022)

Vision Benefit

• Anthem Blue View Vision (Anthem medical plans)
  • Booklet (2022)
  • Summary (2023)

• Booklet (04/22)

Group Life Insurance Plan

• Booklet (2020)

Long-Term Disability Insurance Plan (LTD Plan)

• Booklet (2020)

Supplemental Life Insurance

• Booklet (2020)

Supplemental AD&D

• Booklet (2020)

Retirees Under Age 65:

• Anthem U65 Medical Plan Summary (2023)
• Anthem U65 Medical Plan Summary of Benefits and Coverage (2023)
• Blue View Vision Summary (2023)
• Anthem U65 Medical Plan Booklet (2023)

Retirees Age 65 and Over:

• Blue Retiree Plan Booklet (2023)
• Blue Retiree Plan Summary (2023)
  
• Anthem Blue View Vision Summary (2023)

Base Retirement Plans

• IU Retirement Plan
  • Plan Document (1/20)
• Retirement & Savings Plan
  • Plan Document (1/20)
• PERF Member Handbook (link goes to state government site)

Supplemental Retirement Plans

• IU Tax Deferred Account Plan
  • Plan Document (1/20)
    
• IU 457(b) Retirement Plan
  • Plan Document (12/20)

Legacy Plans

• IU 18/20 Retirement Plan
  • Plan Document (10/14)
• IU Replacement Retirement Plan
  • Plan Document (4/16)
• IUSERP
  • Plan Document (12/20)

• Booklet (04/22)
• Summary (01/23)

IU Tuition Benefit Plan

• Booklet (10/21)
• Summary (10/21)