Benefits-Related Forms

Below are links to the most commonly used benefits forms.  If there is a form not currently listed which you would like to see added, contact the web content manager. 

Flexible Spending Account (FSA) Reimbursement claim Form Direct Deposit Authorization Leave Donation Recipient Application Donor Application Leave Balance Adjustment Medical Related Forms Humana Medical Claim Form Humana Dental Claim Form  Mail Order Prescription Form Handicapped Child -Physician's Certification UNUM Disability/Life Insurance Claim  Form Life Insurance Beneficiary Designation Coordination of Benefits Spouse/Domestic Partner Surcharge - AAUP Surcharge - AFSCME/IUOE Surcharge - All Others 2008 Domestic Partner Affidavit

Miscellaneous Forms Tuition Remission Termination Clearance Form Appeal Retirement Plan Election Form (ARP)  Employment not covered by Social Security - OPERS Employment not covered by Social Security - STRS Medicare D Creditable Coverage Letter - Employees Medicare D Creditable Coverage Letter - Retirees Ohio Public Employees Retirement System Personal History Form Request for Optional Exemption as a Student (F3)  A4-T Traditional Plan Refund Application A4-CO Combined Plan Refund Application A4-MD Member-Directed Refund Application A4-ARP Transfer Funds to an ARP Account Re-employed OPERS Retiree ARP Provider Change Form - 2008