Forms

Most of these forms are PDFs. Many of them can be completed and submitted electronically. To do so download the PDF to your computer first.

 

Beneficiaries

Insurance Plans

Add or change beneficiaries for the IU insurance plans

Online at the Employee Center (select Benefits).

Or download and complete a PDF of the form:

Retirement Plans

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

Fidelity Investments
TIAA
PERF

Health Savings Account (HSA)

Change the beneficiaries on your HSA at Nyhart IU Online Services.

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, IUPUI, 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, and Prescription)
Insurance

Basic Life Insurance

Add or change beneficiaries online at the Employee Center (select Benefits) or download and complete the PDF.

Long-term Disability Insurance

Claim Packet

Enrollment form

Medical History Statement

Personal Accident Insurance (PAI)

Add or change beneficiaries online at the Employee Center (select Benefits) or download and complete the PDF.

Enrollment form (web form)

Supplemental Life Insurance

Add or change beneficiaries online at the Employee Center (select Benefits) or download and complete the PDF.

Enrollment Form

Medical History Statement

Personal Information and 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.

Personal Profile Form (PSA)
To be completed by the employee who wants to be identified as a person with a disability

Retirement plans

PERF

See the INPRS web site for PERF forms

Salary Deferral Agreements

IU Retirement Savings Plan 457(b)

IU Tax Deferred Account (TDA)

Beneficiaries

To add or change beneficiaries contact the company(ies) directly:
Fidelity Investments
TIAA
PERF

Student Health Insurance

IU Health Center Claim Form (PDF)

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

Tax Savings (Commuting, HSA, and TSB)
Tuition Benefit and IUHS

Online IU Tuition Benefit Enrollment Form
      Also available as a PDF:
         2016-17 Academic Year
         2017-18 Academic Year

IUHS Tuition Waiver Form

Unsafe Working Conditions

Service Maintenance positions Bloomington:
Unsafe Working Conditions (Also available as a Word doc)

To complete and submit this form digitally, download it to your computer first.

 

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