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:
- 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.
Health Savings Account (HSA)
Change the beneficiaries on your HSA at Nyhart IU Online Services.
Drug Testing
- 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)
Employment
- 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 Temporary Employee (requires IU logon)
- Telephone Reference Check (Bloomington campus)
Temporary 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
Grievance & Staff Reports
Grievance
- Professional and Non-union Support and Service Staff
- Temporary Employees
- Bloomington and Northwest
Support Staff - Bloomington, IUPUI, and South Bend:
Service Employees - Bloomington, East, IUPUI, Kokomo, Northwest, South Bend, and Southeast
Police Service Employees
Staff Report (Bloomington)
- Staff Report (Word doc, for long documents)
- Staff Report (PDF, for short documents)
Health (Medical, Dental, Prescription, & Vision)
Dental
Medical
- Anthem Medical Claim Form (PPO HDHP and PPO $500 plans)
- IU Health Medical Claim Form (IU Health HDHP plan)
- 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 (Anthem PPO Plans)
- EyeMed Out-of-Network Claim Form (IU Health HDHP Plan)
Health Savings Account (HSA)
- HSA Enrollment/Change Form
- HSA Distribution Request (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 Form
- HSA Power of Attorney Form (grant POA over your HSA)
- HSA Transfer Form (transfer your HSA with another vendor to Nyhart)
- Nyhart Mobile App Instructions
Change beneficiaries by logging on to your Nyhart account.
Leaves (FMLA, Military, Parental, etc.)
Leave for Development of Commercial Projects with a Non-University Entity
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 of Absence
Military Leaves
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
- Claim Packet
- LTD Enrollment/Change/Termination Form (PDF)
- Medical History Statement to provide Evidence of Insurability:
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:
Supplemental Dependent Life Insurance
Personal Information & Life Events
Life Events Changes
- Life Events Changes (select Benefits)
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.
Retirement Plans
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:
Beneficiaries
To add or change beneficiaries contact the company(ies) directly:
- Fidelity Investments
- PERF
- TIAA (legacy accounts only)
Salary, Classification, Rewards & Recognition
Student Health Insurance
See the Student Health Insurance web pages for forms specific to each plan
Tax Saver Benefit (TSB) Plan
- TSB Healthcare and Dependent Care Claim form
- Dependent Care Flexible Spending Account Worksheet
- Direct Deposit Authorization/Termination form
- Additional Debit Card Request Form
- List of Eligible Merchants for the TSB Health account
- Mileage Reimbursement Form
- Nyhart Mobile App Instructions
See the qualified Life Events changes page about making changes to your plan.
Tuition Benefit & IU High School
Unsafe Working Conditions
- Service Positions on Bloomington Campus:
Unsafe Working Conditions (Also available as a Word doc)
Plan Documents
Employee Assistance Program
- SupportLinc Flyer (PDF)
Health (Medical, Dental, Prescription, and Vision)
Dental
Medical Care
- IU Health HDHP
- Anthem PPO HDHP
- Anthem PPO $500 Deductible
Prescription Benefit
- Booklet (1/2020)
Vision Wear Benefit
Health Savings Account (HSA)
- Booklet (5/20)
Life, Disability, & Accident Insurance
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)
Retiree Benefits
Retirees Under Age 65:
- Anthem U65 Medical Plan Summary (2021)
- Blue View Vision Summary (2021)
Retirees Age 65 and Over:
Retirement Plans
Base Retirement Plans
- IU Retirement Plan
- Retirement & Savings Plan
- Plan Document (1/20)
- PERF Member Handbook
Supplemental Retirement Plans
Legacy Plans
Tax Saver Benefit (TSB) Plan
Tuition Benefit
IU Tuition Benefit Plan
- Booklet
- Highlights (5/20)