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Benefits Forms

Health Related Forms

Health Enrollment Form (July 2011)
Extended Coverage Enrollment Form (COBRA)
Qualifying Event Notice
Anthem Claim Form
Anthem Blue View Vision Out-of-Network Claim Form (for COVA Care Members)
Flexible Spending Account Reimbursement Form
MyFBMC Visa Card FAQs
DHRM Flexible Reimbursement Account FAQs

Once you enroll in a Medical FRA, MyFBMC Visa cards will be mailed to your home address automatically


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

GMU 403(b) Salary Reduction Agreement
GMU 457 Payroll Authorization Form
457 Plan Participant Enrollment Form
New One-Time Deferral Forms

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)
VSDP Short Term Disability Return to Work

Workers' Compensation Protocol

Workers' Compensation Return to Work Form
Transitional Duty Plan Form
Panel Physician Selection Form
First Report of Accident Form - pdf (16Kb)
VA DMV Disabled Parking Application - pdf (23Kb)
VSDP Handbook - pdf (196Kb)

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