Medical/Dental
|
| Type of Form |
Usage |
Download |
| Affidavit of Marriage |
to enroll spouse in any of the Santa Clara University sponsored health and welfare plans |
PDF |
| Affidavit of Registered Domestic Partner |
to enroll domestic partner in any of the Santa Clara University sponsored health and welfare plans |
PDF |
| Benefits Enrollment |
for new and current members; use for enrollment, changes or waiver of medical/dental benefits |
PDF |
| |
| Blue Cross Member Claim |
for filing medical claims |
PDF
|
| Blue Cross Authorization |
employee's authorization for the use and/or disclosure of his/her protected Blue Cross health information |
PDF |
| |
| Kaiser Authorization |
employee's authorization for the use and/or disclosure of his/her protected Kaiser health information |
PDF |
| Kaiser Student Certification |
certification that student has met all requirements for coverage under subscriber's account |
PDF |
| |
Health Savings Account
|
| Type of Form |
Usage |
Download |
| Mellon HSA Solution Trustee-to-Trustee Transfer Form |
to initiate a trustee-to-trustee transfer of funds from an existing Health Savings Account (HSA) into the Mellon HSA Solution (for Blue Cross HSA (Compatible) High Deductible PPO members only) |
PDF |
| |
Pretax Medical Expense Account
|
| Type of Form |
Usage |
Download |
| Dependent Care Reimbursement Account Claim Form |
for expense reimbursement from dependent care reimbursement account(s) |
PDF |
| Dependent Care Reimbursement Account Claim Form - Additional pages |
for expense reimbursement from dependent care reimbursement account(s) - additional pages |
PDF |
| Health Care Reimbursement Account Claim Form |
for expense reimbursement from health care reimbursement account(s) |
PDF |
| Health Care Reimbursement Account Claim Form - Additional pages |
for expense reimbursement from health care reimbursement account(s) - additional pages |
PDF |
| Section 125 Enrollment |
for enrollment to medical expense and/or dependent care reimbursement account(s) |
PDF |
| |
Retirement
|
| Type of Form |
Usage |
Download |
| Fidelity 401a Beneficiary Designation |
for adding or changing a beneficiary to your 401a account |
PDF |
| Fidelity 401a Enrollment Guide |
for account transfers, rollovers and exchanges; enrollment guide and fund information provided |
PDF |
| Fidelity 403b Beneficiary Designation |
for adding or changing a beneficiary to your 403b account |
PDF |
| TIAA-CREF Beneficiary Designation |
for adding or changing a beneficiary to your 401a and 403b accounts |
PDF |
| |
| Salary Reduction Agreement 2010 with instructions |
for enrollment or changes to your voluntary tax-deferred Annuity Contributions and/or changes to your fund sponsor. |
PDF |
| Salary Reduction Agreement 2009 with instructions |
for enrollment or changes to your voluntary tax-deferred Annuity Contributions and/or changes to your fund sponsor. |
PDF |
| |
Tuition Remission/Tuition Exchange
|
| Type of Form |
Usage |
Download |
| Intent to Register Application |
for eligible employees and/or their eligible dependents seeking Tuition Remission |
PDF
|
| Job-Related Education Verification Form |
to verify that graduate education benefit is job-related and not be included in the employee's taxable wages |
WORD
|
| Tuition Exchange Application Instructions |
information and instructions for completing the Tuition Exchange Application form |
HTML |
| Tuition Exchange Application Form |
form |
PDF |
| |
Other Benefits
|
| Type of Form |
Usage |
Download |
| ACE Transit Ticket Order Instructions |
Information and instructions for completing the ACE Transit Ticket Order form |
HTML |
| ACE Transit Ticket Order Form |
form |
PDF |
| Donation of Vacation Hours / Request for Additional Vacation Hours |
form |
PDF
WORD |
| MetLife Beneficiary Designation |
for adding or changing a beneficiary to your MetLife Life/AD&D insurance policy |
PDF |
