Forms

BENEFITS — HEALTH, DENTAL & VISION PLAN INFORMATION 

BCBSM Simply Blue HSA High Deductible PPO Plan 
BCN HMO HSA High Deductible Plan
BCN HMO Traditional Plan
Blue Care Network - How it Works
Blue Care Network - Travel
Blue Care Network Contact Numbers
Blue Cross Blue Shield Custom Drug List Formulary
Blue Cross Blue Shield Plan Coverage Comparisons
Dental Benefits at a Glance
Vision Benefits at a Glance
Dependent Care Flexible Spending Account (FSA) 
Employee Flexible Spending Account (FSA) 

Winning with a Health Savings Account (HSA)
FAQs Related to Plans Offered for 2018 Open Enrollment
Employee Assistance Program

BENEFITS — HEALTH, DENTAL & VISION ENROLLMENT & DEDUCTION FORMS 

Enrollment Forms - Administrator & Supervisor 
Enrollment Forms - Classified
Enrollment Forms - Early Childhood
Enrollment Forms - LIPSA
Enrollment Forms - Teacher Assistant
Guardian Enrollment Form
Flexible Spending Account (FSA) Deduction Form
Health Savings Account (HSA) Deduction Form

BENEFITS — LIFE and AD & D INSURANCE PLAN INFORMATION 

Life and AD & D Insurance Policy - Administrator & Supervisor
Life and AD & D Insurance Policy - Classified
Life and AD & D Insurance Policy - Early Childhood
Life and AD & D Insurance Policy - LIPSA

Term Life Insurance Policy - RTC
Term Life Insurance Policy - RTC ≥ 5 Years of Service
Term Life Insurance Policy - Specialized
Term Life Insurance Policy - Specialized ≥ 5 Years of Service
Life and AD & D Insurance Policy - Teacher Assistant
Life / AD&D & Long-Term Disability Enrollment Form
Life Insurance Beneficiary Designation Form


BENEFITS — LONG-TERM DISABILITY 

Long-Term Disability Policy - Administrator & Supervisor
Long-Term Disability Policy - Classified
Long-Term Disability Policy - Early Childhood
Long-Term Disability Policy - LIPSA
Long-Term Disability Policy - Specialized Transportation
Long-Term Disability Policy - Teacher Assistant
Long-Term Disability Insurance Claim Form


LEAVES OF ABSENCE & FMLA 

FMLA Notice to Employees
FMLA Fact Sheet
FMLA Checklist
Leave of Absence Request
Short-Term Disability Request
FMLA Certification of Health Care Provider - Employee
FMLA Certification of Health Care Provider - Family Member
Return to Work Certification


CONFERENCE ROOM RESERVATIONS 

Conference Room Request Form

FINANCE

Daily Meeting & Mileage Reimbursement Request Form
Purchase Reimbursement Request Form
Purchase Requisition Form

HUMAN RESOURCES 

Address/Telephone/Name Change 
AFSCME Sick Day Cash Out Request
Parent / Volunteer Affidavit
Personnel Action Request
Student Teacher / Intern Affidavit
Third Party Visitor
Transfer/Status Change Request [LIPSA]
Transportation - Bus Driver Signing Bonus (Installment I)
Transportation - Bus Driver Signing Bonus (Installment II)
Transportation - Bus Assistant Signing Bonus
Transportation - Bus Driver Recruiting Bonus
Transportation - Bus Assistant Recruiting Bonus


PAYROLL 

Direct Deposit
Paycheck Codes & Abbreviations
Payroll Schedule 2018-19
W-4 Federal
W-4 Michigan

RETIREMENT 

Office of Retirement Services (ORS)
MiAccount
Social Security Administration
403(b) Presentation
403(b) Enrollment Brochure (effective 01/01/19)
403(b) Default Investment Fund (effective 01/01/19)
Plan Fee Disclosure Statement (effective 01/01/19)

STUDENTS & PARENTS 

Authorization for Publicity 
Field Trip Permission Slip (with Parent / Volunteer Affidavit)
Medical / Emergency Information
Student Incident Report 

WORKER'S COMPENSATION 

Authorization for Treatment 
Employee Incident Report
Answers to FAQs
Process for Filing a Claim
Supervisor's Report of Incident 


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