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Benefits Forms

Health Related Forms
Extended Coverage Enrollment Form (COBRA)
Health Enrollment Form
Qualifying Event Notice
Anthem Claim Form
Flexible Spending Account Reimbursement Form
EZ Reimburse Card Information (new employees)
Please note: Completing an EZ Reimburse Card application does not enroll you in a Medical Flexible Account.
EZ Reimburse Card Application
More Health and Flexible Benefits Forms (DHRM)
Proof of Eligibilty

Retirement Related Forms
Retirement and Life Insurance Forms (VRS)
Faculty Retirement Transition Leave Program: Election Form
Faculty Retirement Transition Leave Program: General Release and Covenant Not to Sue form

Family and Medical Leave Act (FMLA) Forms
FMLA Leave Request Form
FMLA Leave Supplement Form
FMLA Certification Form
FMLA Designation Form
Extended Leave Request (Supervisor Notification)
Return to Work Form
Certification for Serious Injury or Illness of Covered Service Member for Military Family Leave
Certification of Qualifying Exigency for Military Family Leave

Virginia Sickness and Disability Program (VSDP) Forms
Extended Absence Leave Supplement Form
Extended Leave Request (Supervisor Notification)
Return to Work Form

Workers' Compensation Protocol

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