Forms and Resources

On this site you may access forms which are available to be viewed and printed. To access any of the following forms, click on the form you are interested in, and then use the print feature in the application it is displayed in. To view PDF files you need to get Adobe Acrobat Reader.

Medical

    2016-2017 Medical Waiver Form   –  All employees who choose the medical waiver need to complete a new  form yearly.

    2016-2017 Med Premium Rates sheet

Summary of Benefits and Coverage – Plan A

Summary of Benefits and Coverage – Plan B

Summary of Benefits and Coverage – Plan C

Summary of Benefits and Coverage – HDHP

    Wellmark Application Form –  Use this form to change plans at open enrollment

    Personal Doctor Selection Form –  Use this form with Plan B and Plan C

    HSA Enrollment Form

    2016 2017 HSA Payroll Deduction Form

    Wellmark Preventive Services covered under The Affordable Care Act

    Glossary of Terms

    Plan A Certificate

    Plan B Certificate

    Plan C Certificate

    HDHP Certificate

   ProAct Rx Summary – Plans A, B, C and Plan HDHP

   SCMeds (CanaRx)

   Identity Protection Flyer

   Identity Protection Member QA

Dental/Vision

     2016-17 Dental Vision Premiums

Dental Enrollment Form

Dental Benefit Summary

Delta Dental Benefits Certificate

Delta Privacy Notice

VSP Enrollment Form

Vision Benefit Summary

VSP Benefit Certificate 

      VSP Out of Network Claim Form  –  Use this form if you have an out of network provider

 

Flexible Spending  Accounts

     Kabel FSA Election Form  –  Use this form at open enrollment to make changes to your flex spending  accounts or to add a flex spending account

     Kabel FSA Brochure

     Kabel – Summary Plan Description

     Kabel – FAQ’s 

     Kabel – Reimbursement Request Form

     BeneFIT Access Claim Form        

Life Insurance

     Life Insurance Enrollment Form  –  Use this form for new hires and to change beneficiaries

     Evidence of Insurability Form  –  Use this form if you want to add additional optional coverage

POLICY – SUN LIFE ASSURANCE COMPANY OF CANADA

Group Life and Accidental Death & Dismemberment Plan

Group Long Term Disability Insurance Plan

Tuition Remission/Exchange

     Tuition Remission Application

     Tuition Exchange Application

Employment Classifications

      Working With Staff

      Working With Faculty

Voluntary Time Schedule Reduction

Letter of Agreement

Voluntary Schedule Reduction 

Application 

Payroll Forms

       Direct Deposit 

       Check by Mail – authorization form for Simpson to mail your wages

Federal W-4

Iowa W-4

I-9

 Name Change

Apply to the Social Security Administration for a new card,  provide HR with a copy of the new card to make the change.

SSA Name Change