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
Tax Sheltered Annuity 403b
Tax Sheltered Annuity 457b
WORKER'S COMPENSATION
Authorization for Treatment  
Worker's Compensation Procedures 
Employee Incident Report
Supervisor's Report of Incident 



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