Forms

BENEFITS — HEALTH, DENTAL & VISION PLAN INFORMATION
BCBSM Community Blue 4 Traditional PPO Plan 
BCBSM Simply Blue HSA High Deductible PPO Plan 
BCN HMO HSA High Deductible Plan
BCN HMO Traditional Plan
Blue Care Network - How it Works
Blue Care Network - Travel
Blue Care Network Contact Numbers 
Blue Cross Blue Shield Custom Drug List Formulary
Blue Cross Blue Shield Plan Coverage Comparisons
Dental Benefits at a Glance
Vision Benefits at a Glance 
Dependent Care Flexible Spending Account (FSA) 
Employee Flexible Spending Account (FSA)  
Winning with a Health Savings Account (HSA)
Open Enrollment Presentation (2018)  
FAQs Related to Plans Offered for 2018 Open Enrollment
Employee Assistance Program
 
BENEFITS — HEALTH, DENTAL & VISION ENROLLMENT & DEDUCTION FORMS
Enrollment Forms - Administrator & Supervisor 
Enrollment Forms - Classified
Enrollment Forms - Early Childhood
Enrollment Forms - LIPSA
Enrollment Forms - Teacher Assistant
Guardian Enrollment Form 
Flexible Spending Account (FSA) Deduction Form (2018)
Health Savings Account (HSA) Deduction Form (2018)
 
BENEFITS — LIFE and AD & D INSURANCE PLAN INFORMATION 
Life and AD & D Insurance Policy - Administrator & Supervisor
Life and AD & D Insurance Policy - Classified 
Life and AD & D Insurance Policy - Early Childhood 
Life and AD & D Insurance Policy - LIPSA 
Life and AD & D Insurance Policy - RTC ≤ 4 Years of Service/25 hrs
Life and AD & D Insurance Policy - RTC ≥ 5 Years of Service/25 hrs
Life and AD & D Insurance Policy - Specialized ≥ 4 Years of Service/20 hrs 
Life and AD & D Insurance Policy - Specialized ≥ 5 Years of Service/20 hrs 
Life and AD & D Insurance Policy - Teacher Assistant
Life / AD&D & Long-Term Disability Enrollment Form 
Life Insurance Beneficiary Designation Form 
 
BENEFITS — LONG-TERM DISABILITY
Long-Term Disability Policy - Administrator & Supervisor
Long-Term Disability Policy - Classified 
Long-Term Disability Policy - Early Childhood 
Long-Term Disability Policy - LIPSA
Long-Term Disability Policy - Specialized Transportation 
Long-Term Disability Policy - Teacher Assistant 
Long-Term Disability Insurance Claim Form 
 LEAVES OF ABSENCE & FMLA
 FMLA Notice to Employees
 FMLA Fact Sheet
 FMLA Checklist
 Leave of Absence Request
 Short-Term Disability Request 
 FMLA Certification of Health Care Provider - Employee
 FMLA Certification of Health Care Provider - Family Member
 Return to Work Certification
 
CONFERENCE ROOM RESERVATIONS
Conference Room Request Form
FINANCE
Daily Meeting & Mileage Reimbursement Request Form 
Professional Learning Approval & Reimbursement Request Form
Purchase Reimbursement Request Form
Purchase Requisition Form
 HUMAN RESOURCES
Address/Telephone/Name Change 
AFSCME Sick Day Cash Out Request 
Parent / Volunteer Background Check
Personnel Action Request 
Student Teacher / Intern Affidavit
Third Party Visitor 
Transfer/Status Change Request [LIPSA]
Transportation - Bus Driver Signing Bonus (Installment I)
Transportation - Bus Driver Signing Bonus (Installment II) 
Transportation - Bus Assistant Signing Bonus
Transportation - Bus Driver Recruiting Bonus 
Transportation - Bus Assistant Recruiting Bonus  
PAYROLL
Direct Deposit
Paycheck Codes & Abbreviations
Payroll Schedule 2017-18
W-4 Federal
W-4 Michigan
RETIREMENT
Office of Retirement Services (ORS)
MiAccount 
Social Security Administration
403b & 457b Agent List
403b Payroll Agreement 
457b Payroll Agreement 
WORKER'S COMPENSATION
Authorization for Treatment  
Worker's Compensation Procedures 
Employee Incident Report
Supervisor's Report of Incident 



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