Documents & Forms

Flexible Benefit Plan

• Annual Salary Reduction Agreement
• Dependent Care Reimbursement Account Reimbursement Form
• Flexible Spending Account Reimbursement Form

Lay Employees' Retirement Plan

• Direct Deposit Form
• Federal Tax Withholding Form
• LERP Beneficiary Designation Form for Plan Death Benefit
• Michigan Tax Withholding Form
• Michigan Tax Withholding Worksheet
• Request for Pension Estimate
• Request for Retirement Application Kit

Legally Domiciled Adult

• Legally Domiciled Adult Certification Form
• Legally Domiciled Adult Decertification Form
• Legally Domiciled Adult Tax Treatment Certification Form

Life Insurance

• Life and Accidental Death & Dismemberment Insurance Beneficiary Designation Form
• Online UNUM Evidence of Insurability Form
• Instructions for Online UNUM Evidence of Insurability Form
• Printable UNUM Evidence of Insurability Form
• UNUM Voluntary Term Life Insurance Beneficiary Designation Form

Long Term Disability Plan

• LTD Claim Form

MCC 403(b) Retirement Savings Plan

• 403(b) Enrollment Form
• 403(b) Beneficiary Designation Form
• 403(b) Salary Reduction Agreement

Medical, Dental, and Vision Plans

• Authorization for Release of Protected Health Information
• BCBSM Member Reimbursement Claim Form
• BCBSM Prescription Drug Reimbursement Claim Form
• BCN Member Reimbursement Claim Form
• BCN Prescription Drug Reimbursement Claim Form
• Delta Dental Out of Network Claim Form
• Notice of Creditable Prescription Drug Coverage
• VSP Out of Network Claim Form

Short Term Disability Plan

• Form W-4 (Federal Tax Withholding Form)
• Form MI-W4 (Michigan Tax Withholding Form)
• Short Term Disability Authorization Agreement Electronic Funds Transfer
• Short Term Disability Application
• Short Term Disability Continuing Disability Statement

Unit Benefit Changes

• Unit Program Add/Remove Form

Required Notices

• Children’s Health Insurance Program (CHIP) Notice
• HIPPA Privacy Policy and Procedures for Protected Health Information
• Newborn’s and Mother’s Health Protection Act Notice
• Special Enrollment Rights Notice
• Women’s Health and Cancer Rights Act Enrollment Notice
• Your Rights and Protections Against Surprise Medical Bills

New Hire/Newly Eligible Employee Enrollment Guide

The “New Hire/Newly Eligible Employee Enrollment Guide” can now be found on the “New Hires/Newly Eligible Employees” page.