Forms & Plan Documents

Forms

To complete a PDF form electronically, download it to your computer and open in Adobe Reader.

Affidavits and Certifications

Beneficiaries

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

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

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

Benefit Changes

Life Events Changes

Optional Benefit Changes

Drug Testing

Employment

Part-Time Positions Employment Applications

Flexible Spending Accounts (FSA)

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

Grievance & Corrective Action/Counseling Forms

Grievance

Corrective Action/Counseling Form

Health (Medical, Dental, Prescription, & Vision)

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

  • Download the CIGNA Dental Claim Form by logging in to Cigna.com and selecting Claims from the main navigation.

Medical

Prescription

Vision

Health Savings Account (HSA)

Change beneficiaries by logging in to your WEX account at www.benefit-info.com/iu/.

Leaves (FMLA, Military, Parental, etc.)

FMLA (Family and Medical Leave Act)

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

Leave of Absence

Military Leaves

Paid Living Donor Leave

Paid Parental Leave

Life & Voluntary Insurance Plans

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

Supplemental Accidental Death & Dismemberment (AD&D)

Supplemental Life Insurance

Supplemental Dependent Life Insurance

Personal Information

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

Personnel Records Release

Retirement Plans

PERF

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:

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

Salary, Classification, Rewards & Recognition

Student Health Insurance

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

Tuition Benefit & IU High School

Unsafe Working Conditions

Plan Documents

Employee Assistance Program

Flexible Spending Accounts (FSA)

Health (Medical, Dental, Prescription, and Vision)

Dental

Medical Care

Prescription Benefit

Vision Benefit

  • Anthem Blue View Vision (Anthem medical plans)

Health Savings Account (HSA)

Life & Voluntary Insurance Plans

Group Life Insurance Plan

Long-Term Disability Insurance Plan (LTD Plan)

Supplemental Life Insurance

Supplemental AD&D

Retiree Benefits

Retirees Under Age 65:

Retirees Age 65 and Over:

Retirement Plans

Base Retirement Plans

Supplemental Retirement Plans

Legacy Plans

Tuition Benefit

IU Tuition Benefit Plan