Human Resources

Staff Benefits Forms

• All forms are PDF   format, unless otherwise noted, download the free reader
• Open Enrollment Application (Health, Dental, Prescription Drug Coverage)
• 2010 Salary Conversion Election Form - Health Coverage
• 2010 Salary Conversion Election form - Vision Coverage
• Indiana State University Application for Faculty/Staff Spouse Fee Waiver 
• Indiana State University Application for Faculty/Staff Fee Waiver
• Indiana State University Application for Staff Dependent Child Fee Waiver
• Indiana State University Tax Deferred Annuity Agreement Form 
• Group Employee Application for Health, Dental and Prescription Drug Card Coverage
• Application for Late Enrollment for Health, Dental and Prescription Drug Card Coverage 
• Application for Change in Enrollment in Health, Dental and Prescription Drug Card Coverage 
• Cancellation of Health Dental and Prescription Drug Card Coverage 
• Medical Claim Form
• Delta Dental Claim Form 
• Application for United Healthcare Vision (Spectera) (Vision Coverage)
• Anthem Prescription Claim Form
• Prescription Mail Order Form
• Flexible Spending Account Application
• List of Documentation for I9 (Employment Eligibility Verification) Form
• Student Certification for Spring 2009
• Voluntary Sick Leave Donation Agreement Form
• Sick Leave Transfer Medical Form
• Phased Retirement Application
• Salary Reduction Form ( under section 403(b) or 457(b))