Benefits Info & Forms

are available whenever you need them. All forms are in .pdf format unless otherwise noted.

AcrobatReader is needed to download .pdf forms.

Please turn in signed paperwork to the Human Resources Department for all changes.

Insurance | Medical, Vision, Dental

A Life Event change must be reported within 30 days of the event, or the change will not become effective until the next Open Enrollment period. 

Benefit Summaries (2011-2012 Plan Year)	Faculty Administrators and Professional (Exempt) Staff Non-Exempt Staff Non-Exempt-Staff (Facilities and Public Safety) Flexible Benefits Worksheet (2011 - 2012) Summary Annual Report Summary Plan Description
Blue Care PPO ($300 deductible)	Benefit Summary Plan Enrollment/Change Form Claim Form Dependent Supplement Mail Order Pharmacy Application Tier Zero Prescription Drugs PPO $300 Deductible SPD Website: www.bcnepa.com ; www.bcbs.com Phone Number: 1-888-338-2211
Blue Care® HMO	Benefit Summary Plan Enrollment/Change Form Dependent Supplement Mail Order Pharmacy Application Tier Zero Prescription Drugs HMO SPD Website: www.bcnepa.com Phone Number: 1-800-822-8753
Blue Care PPO ($1000 Deductible)	Benefit Summary Plan Enrollment/Change Form Dependent Supplement Mail Order Pharmacy Application Tier Zero Prescription Drugs PPO $1000 Deductible SPD Website: www.bcnepa.com Phone Number: 1-800-822-8753
United Concordia Dental	Basic Dental Booklet Enhanced Dental Booklet  Enrollment/Change Form  Identification Card Information Website: www.ucci.com Phone Number: 1-800-332-0366
Davis Vision	Benefit Summary Enrollment/Change Form Website: http://idoc.davisvision.com Phone Number: 1-800-406-1324
Flexible Spending Accounts (AmeriFlex 06/01/2011- 05/31/2012)	Enrollment Form  Direct Deposit Election Claim Form Eligible Expenses (Medical FSA) Change to Benefit AND/OR Election Health Care Reform - Over the Counter Changes Form FAQ  Website: www.flex125.com Phone Number: 1-888-868-FLEX (3539)
SunLife (Life and AD&D)	Beneficiary Form  Optional Life Enrollment Form Evidence of Insurability Additional ADD Enrollment Group Booklet ADD Booklet
TIAA-CREF	2011 Contribution Information 2012 Contribution Information TIAA-CREF Enrollment: http://enroll.tiaa-cref.org/wilkes/ Wilkes University Pension DC 103455 SPD Wilkes University Pension TDA 103457 SPD Salary Reduction Agreement (PDF) 2010 SAR DC 2010 SAR TDA 403(b) Universal Availiblity Notice
Tuition Remission	Employee Spouse/Dependant Tuition Benefit Policy
Workers' Compensation	Policy/Procedures Workers' Compensation General Information Employee Injury Report  Notice of Rights and Duties  Panel Providers  Release of Medical Information  Supervisor Checklist