Employee Benefits Forms
American International Group (AIG) Accident Insurance
AIG Cancellation Form
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 Change In Status Form
PEIA Change of Beneficiary Form
PEIA Out-of-Area Dependent Form
PEIA Medical Claim Form
(form needed for reimbursement of payment for flu vaccine)
PEIA Tobacco Affidavit
PEIA Plans A,B, and C Advance Directives Forms
WV Living Will
WV Medical Power of Attorney
WV Living Will & Medical Power of Attorney combined
Mountaineer Flexible Benefits
FBMC Change-in-Status Form
FBMC FSA Claim Form
Delta Dental Claim Form
Paycheck Abbreviations Explanations
Retirement-TIAA-CREF
WVU - TIAA-CREF Booklet
“Choosing Your Investments”
TIAA-CREF Beneficiary Change Form
TIAA-CREF Name Change Form
TIAA-CREF Change in Allocation Form
(send completed form directly to TIAA-CREF)
TIAA-CREF 403(b) Enrollment Form
In addition, please submit an
SRA Salary Reduction Agreement 403(b)-457(b)
with enrollment. This form instructs WVU on how much an employee wishes to contribute each pay.
TIAA-CREF 457(b) Enrollment Form
In addition, please submit an
SRA Salary Reduction Agreement 403(b)-457(b)
with enrollment. This form instructs WVU on how much an employee wishes to contribute each pay.
Retirement- Great West
Great West 403(b) Enrollment Form
Please submit an
SRA Salary Reduction Agreement 403(b)-457(b)
with enrollment. This form instructs WVU on how much an employee wishes to contribute each pay.
SRA Salary Reduction Agreement 403(b)-457(b) with enrollment. This form instructs WVU on how much an employee wishes to contribute each pay.
Supplemental Retirement Annuities (SRA)
SRA Salary Reduction Agreement 403(b)-457(b)
Non-Benefits Eligible Salary Reduction Agreement 403(b) Only
Retiree Insurance
Retiree Medicare Information Letter
PEIA Retiree Health Benefits and Basic Life Enrollment Form
PEIA Retiree Optional/Dependent Life Enrollment Form
FBMC Retiree Enrollment Form - Plan Year 2012
–
(for employees retiring through the end of May 2012)
FBMC Retiree Enrollment Form - Plan Year 2013
–
(for employees retiring in June 2012 and later)
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 Tax Forms
WVU Long-Term Disability
WVU Long-Term Disability Cancellation Form
WVU Long-Term Disability Enrollment Form
WVU Long-Term Disability Evident of Insurability Form (PA/OH)
WVU Long-Term Disability Evidence of Insurability Form (WV)
WVU Long-Term Disability Rates Chart
Years of Service
Request for Years of Service Verification Form
Retiree Accrued Leave-YOS Conversion Form
