Forms

• Flexible Benefit Plan Election Form
• Blue Cross Medical Enrollment Form
• POS Claim Form
• PPO Out of Network Claim Form
• International Claim Form
• Davis Vision Claim Form
• Health Savings Account (HSA) Election Form
• Health Savings Account (HSA) HealthEquity New Account Form

• Dental Election Form
• Delta Dental Enrollment Form
• Delta Dental Claim Form

Please note that while a "paper" claim form is available, it is recommended you submit claims directly through the Inspira Portal.

• Flexible Spending Account (FSA) Election Form
• Flexible Spending Account (FSA) Claim Form

• Lincoln Financial Life Insurance Beneficiary Form
• Lincoln Financial Life Insurance Medical Underwriting Application for supplemental insurance
  • Online Application

• Family Medical Leave Act (FMLA) Request Form
• Short Term Disability (STD) Application

• I-9 Employment Eligibility Verification Form
• Address Change Form (you must also complete a PA Earned Income Tax Form and send to Payroll)
• Attendance Record 2025 (track paid time off: vacation, personal, sick, etc.)
• Attendance Record 2024 (track paid time off: vacation, personal, sick, etc.)
• Emergency Contact Form
• Employee Information Sheet
• Job Posting Form
• Lactation Space Request Form
• Non-employee Information Sheet (volunteers, research associates, etc.)
• Position Request Form
• Timesheet: Bi-weekly
• Timesheet: Monthly
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• Flex-time Request Form
• Gym/Library Application for Spouses
• Tuition Grant Application
• Tuition Remission Form