Benefits Forms Library

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	Affidavit of Common Law Marriage		Acrobat PDF		Use to certify an opposite-sex common law spouse for benefits eligibility

 

	MetLife Dental Claim Form		Acrobat PDF

 

	Affidavit of Domestic Partnership		Acrobat PDF		Use to certify a same-sex common law spouse for benefits eligibility

 

	Termination of Domestic Partnership		Acrobat PDF		Use to dissolve same-sex common domestic partnership

 

	Group Life Insurance Beneficiary Designation – Aetna		Acrobat PDF		Use this form to newly elect or update your life insurance beneficiary.

 

	AmeriHealth/UPHS Point of Service Self-Referred Claim Form		Acrobat PDF
	Keystone/UPHS Point of Service Self-Referred Claim Form		Acrobat PDF
	PENNCare/Personal Choice Out-of-Network Claim Form		Acrobat PDF

 

	How to File Claims for Services with Penn Behavioral Health		Acrobat PDF
	Penn Behavioral Health Claim Form		Acrobat PDF

 

	Visiting Scholar Health Coverage Worksheet – FY10		Acrobat PDF
	Visiting Scholar Health Premiums – FY10		Acrobat PDF

 

	Caremark Prescription Drug Claim Form		Acrobat PDF
	Caremark Prescription Drug Mail Order Form		Acrobat PDF

 

	Health Care Pre-Tax Expense Account: Request for Reimbursement		Acrobat PDF
	Dependent Care Pre-Tax Expense Account: Request for Reimbursement		Acrobat PDF
	Pre-Tax Expense Account Direct Deposit Authorization		Acrobat PDF		Use this form to have your Pre-Tax Expense Account reimbursements directly deposited into a checking or savings account

 

	Physician's Certification for Employee		Acrobat PDF
	Physician's Certification for Family Member		Acrobat PDF
	Short Term Disability & Family Medical Leave Request Form		Acrobat PDF
	Intermittent Leave Tracking Form		Acrobat PDF
	Work Sheet For Calculating Monthly Sick Balances		Acrobat PDF
	Qualifying Exigency Leave Form		Acrobat PDF
	Illness of Covered Servicemember Form		Acrobat PDF
	Family and Medical Leave (FMLA) Provisional Letter #1 – Policy 631		Word 97/2000		Staff member has been out sick for more than 3 consecutive days and has not notified you.
	Family and Medical Leave (FMLA) Provisional Letter #2 – Policy 631		Word 97/2000		Staff member has notified you s/he will be out for possible FML qualifying event for his/her own serious medical condition.
	Family and Medical Leave (FMLA) Provisional Letter #3 – Policy 631		Word 97/2000		Staff member has notified you s/he will be out for possible FML qualifying event to care for family member with a serious medical condition.
	Family and Medical Leave (FMLA) Provisional Letter #4 – Policy 631		Word 97/2000		Staff member has notified your s/he will be out for possible FML qualifying event for birth/placement of a child for adoption.
	Family and Medical Leave (FMLA) Provisional Letter #5 – Policy 631		Word 97/2000		Staff member has notified you that s/he will be out for a possible FML qualifying event because of any qualifying exigency arising out of the fact that a spouse, son, daughter or parent of the employee is on active duty (or has been notified of an impending call or order to active duty) in the armed forces or in support of a contingency operation.
	Family and Medical Leave (FMLA) Provisional Letter #6 – Policy 631		Word 97/2000		Staff member has notified you that s/he will be out for a possible FML qualifying event due to the serious injury or illness of a covered servicemember for military family leave.

 

	Prior Service Credit: Employee Certification		Acrobat PDF		Use to waive the 1-year waiting period under the TDR
	Prior Service Credit: Sample Letter from Prior Employer		Acrobat PDF		Use to waive the 1-year waiting period under the TDR
	Calculating Your Maximum Contribution Amount Per Pay Period (TDR)		Acrobat PDF		Use to calculate your contribution amount per pay period if you want to contribute your maximum amount
	TIAA-CREF Beneficiary Form		Acrobat PDF		Use to designate beneficiary
	Vanguard Beneficiary Form		Acrobat PDF		Use to designate beneficiary
	Visit www.hr.upenn.edu/retirement or call the Retirement Call Center at 1-877-PENN-RET (1-877-736-6738) to enroll for the TDR plan.

 

	Calculating Your Maximum Contribution Amount Per Pay Period (SRA)		Acrobat PDF		Use to calculate your contribution amount per pay period if you want to contribute your maximum amount
	TIAA-CREF Beneficiary Form		Acrobat PDF		Use to designate beneficiary
	Vanguard Beneficiary Form		Acrobat PDF		Use to designate beneficiary
	Visit www.hr.upenn.edu/retirement or call the Retirement Call Center at 1-877-PENN-RET (1-877-736-6738) to enroll for the SRA plan.

 

	Use the online tuition management system to apply for and manage tuition benefits for you, your spouse/same-sex domestic partner, and your children.

 

	Davis Vision Claim Form		Acrobat PDF