Forms & Downloads

Employee Benefits Forms

American International Group (AIG) Accident Insurance
AIG Enrollment Form
AIG Cancellation Form
AIG Plan Summary

Authorization for Release of Information
Authorization for Release of Information Form

How to Change an Address
Change of Address

Child Care Financial Assistance Program
Child Care Financial Assistance Application

Employee Leave
Annual Leave Extension Request Form
Request for Personal Leave of Absence

Optional/Dependent Life Insurance
PEIA Optional/Dependent Life Insurance Enrollment Form
PEIA Basic and Optional Life Change of Beneficiary Form

Other Qualified Adults
WVU Employee Benefits Dependent Identification Card Application Form

Health Insurance (PEIA and Health Plan)
PEIA Shopper’s Guide
PEIA Summary Plan Description PPB Plans A, B, and D
PEIA Summary Plan Description PPB Plan C
Prescription Drug Benefits

PEIA Change In Status Form
PEIA Change of Beneficiary Form
PEIA Out-of-Area Dependent Form
PEIA PPB Plan Medical Claim Form
PEIA Primary Care Physician (PCP) Designation Form

Find a Health Care Provider

View your health claims online with HealthSmart

WV Advance Directives Forms
WV Living Will
WV Medical Power of Attorney
WV Living Will & Medical Power of Attorney combined

Mountaineer Flexible Benefits
Mountaineer Flex Benefits Reference Guide
* Please note MetLife Vision address incorrect in Reference Guide.
Correct address is:
MetLife Vision
PO Box 385018
Birmingham, AL 35238-5018
Mountaineer Flex Benefits Enrollment/Change-in-Status Form
Mountaineer Flex Benefits Active Employee Demographic Change Form
Delta Dental Claim Form
MetLife Vision Out-of-Network Claim Form
Hyatt Legal Fact Sheet
WageWorks Health Care Card (FSA) Claim Form
WageWorks Letter of Medical Necessity
WageWorks FSA Quick Start Guide
WageWorks list of eligible FSA expenses


Retirement-TIAA
WVU – TIAA Booklet
TIAA Change in Allocation Form
(send completed form directly to TIAA)

TIAA 403(b) Enrollment Form In addition, please submit an
SRA Salary Reduction Agreement with enrollment. This form instructs WVU on how much an employee wishes to contribute each pay.

TIAA 457(b) Enrollment Form In addition, please submit an
SRA Salary Reduction Agreement with enrollment. This form instructs WVU on how much an employee wishes to contribute each pay.

TIAA Beneficiary Change
TIAA Change in Address Form

Retirement- Empower Retirement
Empower Retirement 403(b) Enrollment Form Please submit an
SRA Salary Reduction Agreement with enrollment. This form instructs WVU on how much an employee wishes to contribute each pay.

Empower Retirement 457(b) Enrollment Form In addition, please submit an SRA Salary Reduction Agreement with enrollment. This form instructs WVU on how much an employee wishes to contribute each pay.

Empower Beneficiary Change

Supplemental Retirement Annuities (SRA)
SRA Salary Reduction Agreement
Non-benefits Eligible Salary Reduction Agreement

Phased Retirement Program for Faculty and Staff
Phased Retirement Agreement

Sick Leave Buyout Program
Application for Payment of Unused Sick Leave
Sick Leave Buyout Program Federal Tax Forms
Sick Leave Buyout Program State Tax Forms

WVU Long-Term Disability
WVU Long-Term Disability Cancellation Form
WVU Long-Term Disability Enrollment Form
WVU Long-Term Disability Evidence of Insurability Form (PA/OH)
WVU Long-Term Disability Evidence of Insurability Form (WV)
WVU Long-Term Disability Rates Chart
WVU Long-Term Disability Policy Change Request Form

Years of Service
Request for Years of Service Verification Form
Outside Agency Years of Service Verification Form
Retiree Accrued Leave-YOS Conversion Form

Retiree Insurance
Retiree Medicare Information Letter
PEIA Retiree Health Benefits and Basic Life Insurance Enrollment Form
PEIA Retiree Optional/Dependent Life Insurance Enrollment Form
FBMC Retiree Enrollment Form
FBMC Retiree Reference Guide