Forms & Plan Documents

Most of the documents on this page are PDFs. Many of the forms can be completed and submitted electronically. To do so download the PDF to your computer and open in Adobe Reader.

Forms

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 Nyhart IU Online Services.

Benefit Changes

Life Events Changes

Optional Benefit Changes

Drug Testing

Employment

Part-Time Positions Employment Applications

Flexible Spending Accounts (FSA) formerly Tax Saver Benefit (TSB)

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

Grievance & Staff Reports

Grievance

Staff Report (Bloomington)

This form is being updated.

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

Medical

Prescription

Vision

Health Savings Account (HSA)

Change beneficiaries by logging on to your Nyhart account.

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, Disability, & Accident Insurance

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

Health (Medical, Dental, Prescription, and Vision)

Dental

Medical Care

Prescription Benefit

Vision Benefit

  • Anthem Blue View Vision (Anthem medical plans)
  • EyeMed Vision Plan (IU Health medical plan)

Health Savings Account (HSA)

Life, Disability, & Accident Insurance

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

Flexible Spending Accounts (FSA) Formerly Tax Saver Benefit (TSB)

Tuition Benefit

IU Tuition Benefit Plan