Forms

BENEFITS
BCBSM Community Blue 4 Traditional PPO Plan 
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
Dependent Care Flexible Spending Account (FSA) 
Employee Assistance Program
Employee Flexible Spending Account (FSA)  
Enrollment Forms - Administrator & Supervisor 
Enrollment Forms - Classified
Enrollment Forms - Early Childhood
Enrollment Forms - LIPSA
Enrollment Forms - Teacher Assistant
Guardian Enrollment Form 
FAQs Related to Plans Offered for 2018 Open Enrollment 
Open Enrollment Presentation (2018) 
Flexible Spending Account (FSA) Deduction Form (2018)
Health Savings Account (HSA) Deduction Form (2018)
Winning with a Health Savings Account (HSA) 
Life Insurance Beneficiary
Life and AD & D Insurance Policy 
Life and AD & D Insurance Enrollment Form 
Long-Term Disability Policy 
Long-Term Disability Enrollment Form 
Long-Term Disability Insurance Claim Form 
Vision Benefits at a Glance
CONFERENCE ROOM RESERVATIONS
Conference Room Request Form
FINANCE
Daily Meeting & Mileage Reimbursement Request Form 
Professional Learning Approval & Reimbursement Request Form
Purchase Reimbursement Request Form
Purchase Requisition Form
 HUMAN RESOURCES
Address/Telephone/Name Change 
FMLA Certification of Health Care Provider - Employee
FMLA Certification of Health Care Provider - Family Member
FMLA Employee Guide 
FMLA Fact Sheet(s) 
FMLA Notice to Employees 
FMLA Road Map 
Leave of Absence Request 
New Hire Onboarding Packet - Classified 
New Hire Onboarding Packet - Early Childhood
New Hire Onboarding Packet - LIPSA
New Hire Onboarding Packet - Supervisors & Administrators
New Hire Onboarding Packet - Teacher Assistants
New Hire Onboarding Packet - Transportation
Parent / Volunteer Background Check
Personnel Action Request 
Student Teacher / Intern Affidavit
Third Party Visitor 
Transfer/Status Change Request [LIPSA]
PAYROLL
Direct Deposit
Paycheck Codes & Abbreviations
Payroll Schedule 2017-18
W-4 Federal
W-4 Michigan
RETIREMENT
Office of Retirement Services (ORS)
MiAccount 
Social Security Administration
Tax Sheltered Annuity 403b
Tax Sheltered Annuity 457b
WORKER'S COMPENSATION 
Authorization for Treatment  
Worker's Compensation Procedures 
Employee Incident Report
Supervisor's Report of Incident 

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