Benefits/Leave Forms
General Forms
Address/Name Change Form |
Adobe (416KB) |
Word (124KB) |
Community Service Leave Request |
Word (23.5KB) |
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Community Service Leave Request (Tutoring/Mentoring Option ) |
Word (23.5KB) |
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Label Request Form |
Word (62KB) |
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NC Prepaid Legal Services Enrollment Application |
Adobe (43.3KB) |
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Payroll Deduction Cancellation |
Adobe (847KB) |
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Request for Family Medical Leave |
Adobe (895KB) |
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Request for Family Illness Leave |
Adobe (830KB) |
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University Recreation Payroll Deduction |
Adobe (35KB) |
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University Recreation Payroll Cancellation |
Adobe (595KB) |
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Voluntary Shared Leave Release Form |
Adobe (790KB) |
Word (32KB) |
Claims Forms
Attorney Billing |
Adobe (417KB) |
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Conseco Insurance Claim |
Adobe (379KB) |
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Colonial Life Insurance Claim |
Adobe (356KB) |
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AFLAC Claim |
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Disability Forms
Liberty Enrollment |
Adobe (79KB) |
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Liberety Disability Claim |
Adobe (98KB) |
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Liberty Late Entrant |
Adobe (146KB) |
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Standard Disability Claim |
Adobe (252KB) |
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Standard Disability Enrollment |
Adobe (39KB) |
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Standard Late Entrant Enrollment |
Adobe (44KB) |
NC Flex Forms
NC Flex Enrollment |
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NC Flex Forms (Claim Forms, etc...) |
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Retirement Enrollment: Optional Retirement Plan (ORP) Forms
AIG Valic |
Adobe (214KB) |
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Fidelity |
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Lincoln |
Adobe (190KB) |
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TIAA CREF |
Adobe (832KB) |
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For Faculty and EPA Administrative Only |
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ORP Election Form (Complete this form when choosing any of the above ORP plans) |
Adobe (54KB) |
State Retirement Forms
State Retirement Forms Website |
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TSERS |
Adobe (85KB) |
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Beneficiary Change Form |
Adobe (851.4KB) |
(Optional) Supplemental Retirement Programs Forms
401(K) Enrollment (Complete the Beneficiary form (located below) when enrolling) |
Adobe (153.22KB) |
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401(K) Beneficiary Designation Form |
Adobe (124.6KB) |
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401(K) Change Form |
Adobe (130.64KB) |
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403(b) Enrollment Information |
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Auth for 403(b) Salary Reduction Agreement |
Adobe (455KB) |
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457 |
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State Medical Forms
Change Form |
Adobe (90KB) |
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Dependent Eligibility |
Adobe (27.16KB) |
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Enrollment (NC SmartChoice Blue Options PPO Plan) |
Adobe (67.6KB) |
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Medco - Prescription Drug Claim Form |
Adobe (44.35KB) |
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Medco - Prescription Mail Order |
Adobe (61KB) |
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Medical Claim Form (PPO Plan) |
Adobe (74.27KB) |
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Authorization Form (HIPAA) |
Adobe (47.24KB) |
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Prior Coverage |
Adobe (34.24KB) |
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State Appeal |
Adobe (27.69KB) |
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