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 |
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| 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 |
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| 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 |
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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 |
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Pretax Medical Expense Account
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| 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 |
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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 |
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| 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 |
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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 |
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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 |
