University Human Resource Services
University-wide Forms
ADA
Classification
Dependent Child
Domestic Partnership
Employee Relations
Employment
Fee Courtesy
FMLA
Grievance
Insurance
Health, Dental, Prescription
Mass Transit
Personal Profile
Retirement
Reward and Recognition
Salary
Tax Saver Benefit
Timesheets
Application/Affidavit to Establish Dependency by Guardianship
Certification of Disabled Dependent Child Eligibility
Certification of Eligibility for Dependent Child Age 19 or Older
Affidavit of Domestic Partnership
Same-Sex Domestic-Partner Health Plan Benefit Tax Estimation Work Sheet
Authorization Form for Motor Vehicle Records Check (Risk Management)
IU Fee Courtesy 2008-2009 Benefit Enrollment Form
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FMLA Definition of Serious Health Conditions
FMLA Form 1 Leave Notice or Request Approval and Information
FMLA Form 2E Medical Certification for Employee
FMLA Form 2F Medical Certification for Family (of Employee)
FMLA Form 3 Release/Intent to Return to Work
Grievance Form for Hourly Employees
Grievance Form for Professional and Non-union Support and Service Staff
Health, Dental & Prescription Plans
Medical Care
IU PPO Plus, IU PPO $900 Deductible and Blue Preferred POS Plans
Retiree Health Care Enrollment Form (under age 65)
Prescription Plan
IU PPO Plus, IU PPO $900 Deductible, Blue Preferred Primary POS
Anthem Prescription Order Form
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NextRx Prescription Claim Form![]()
M-Plan Health Care Plan
Mental Health and Chemical Dependency
IU PPO Plus and IU PPO $900 Deductible
Dental Plan
Student Health Insurance
International Dependent Enrollment Form 2007-08
International Continuation Form - Fall 2008
International/SAA Temporary ID card
SAA/Fellowship Dependent Enrollment Form 2007-08
Other
Long-term Disability Insurance
Group Long Term Disability Insurance Plan Enrollment Form
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Supplemental Life Insurance
Medical History Statement for Non-Indiana Residents
Basic Life Insurance Plan
Personal Accident Insurance (PAI)
IU Retirement Plan
Investment Company Change Form
IU Retirement Savings Plan 457(b)
Salary Deferral Agreement Form
Fidelity Investments 457(b) Enrollment Form and Beneficiary Designation
IUSERP
IU Tax Deferred Annuity Plan 403 (b)
Account Application Fidelity Investments 403(b) Custodial Account
Public Employee's Retirement Fund (PERF)
Mid-Year Salary Adjustment Form for Professional Staff
-Standard form![]()
-Form to use with 5 or more funding sources![]()
Direct Deposit Authorization/Termination form (TSB & HRA)
Dependent Care Flexible Spending Account Worksheet
Health Care Flexible Spending Account Worksheet (Nyhart)
See the Benefits Change Connection about making changes to your plan
Bloomington Forms
Employee Written Authorization for Release of Personnel File(s)
Grievance Form for Appointed Service Maintenance Employees
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Appointed Service Maintenance positions:
Employment Application
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| RTF version also available
Hourly positions:
Employment Application
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| RTF version also available
* HTML online form template for submitting to a database; available upon request
Education and Work History Supplement
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| RTF version also available
Appointed Staff Position Posting Request Form

