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

    2017-2018 Medical Waiver Form   –  All employees who choose the medical waiver need to complete a new  form yearly.

    2017-2018 Medical Premium Rates

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

    2017 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

    2017 HSA Deduction Form

    2018 HSA 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

Rx Contact Numbers at ProAct

   SCMeds (CanaRx)

FAQ Mail Order Options

   Identity Protection Flyer

   Identity Protection Member QA

Dental/Vision

2017 – 2018 Dental Vision Costs

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

    2017-2018 Kabel FSA Enrollment Form  –  Use this form at open enrollment to make changes to your flex spending  accounts or to add a flex spending account

    2017-2018 Kabel FSA Brochure

    2017-2018 FSA Reimbursement Form

    Kabel – Summary Plan Description

          

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

TIAA

Summary Plan Document

Salary Reduction Agreement

Plan Investment Information

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