Benefit Forms
Accident Reporting Form (for Workers' Compensation)

This form is used to report accidents that occur on campus property.

Alternate-Reduced Work Arrangement

This form is used by employees and supervisors to create an agreement and to describe a work schedule that will vary from the employee's typical work week.  This could be on a long-term or short-term basis.
Basic Retirement Plan Form (12kb)

This form is used to designate the funds for the
Skidmore College Basic Retirement Plan.
Blue Shield of Northeastern NY Direct Claim Form

This form is used to receive direct reimbursement
from Blue Shield of Northeastern NY(Skidmore PPO Plan).

Blue Shield of Northeastern NY Claim Form for Direct Reimbursement for Alternative Health Benefits

This form is to be used for direct reimbursement from Blue
Shield of NENY (Skidmore PPO Plan) for any service under
Alternative Health Benefits:  Acupuncture; Fitness Center
Membership; Homeopathic Care; Hypnotherapy for weight 
control or smoking cessation; Massage Therapy; and 
Nutritional Counseling. 
CDPHP Enrollment Application/Change Form

This form is used to enroll or make changes
to your information with CDPHP.
Dental Claim Form

This form is used to submit dental claims to the provider.
Dental Plan Application

This form is used if you are selecting Dental Plan
A or B as your dental coverage.
Disability Reporting Form

This form is for employees and supervisors to report
a non-work related disability.
Domestic Partner Affidavit

This form is used to add and verify a Domestic Partner
if you are selecting Domestic Partner coverage.
Domestic Partner Dependent Certification

This form is used to enroll a Domestic Partner's qualified
dependent children if you selected Domestic Partner coverage.
Domestic Partner Termination Form

This form is used to remove a Domestic Partner if you selected Domestic Partner coverage.
External Tuition Grant Application

This form is used by Skidmore employees to apply for the External Tuition Grant for their legally dependent children attending a college other than Skidmore.
Faculty Parental Leave Request

This form is used by Skidmore faculty to apply for parental leave.

FMLA Employee Form

This form is used by physicians or practitioners to certify the reason for the leave and is specifically for the serious health condition of an employee. 
FMLA Family Member Form

This form is used by physicians or practitioners to certify the reason for the leave and is specifically for the serious health condition of a family member.
FMLA Request Form

This form is used by Skidmore employees to request leave covered by the Family and Medical Leave Act.
Internal Tuition Grant Application

This form is used for employees who wish to apply for the Internal Tuition benefit.

Life Insurance Beneficiary Designation Form

This form is used by employees who wish to change their group term life insurance beneficiary.
Life Insurance Enrollment Form

This form is used by employees at date of hire or open enrollment who wish to enroll in Dependent Life Insurance for the 1st time.  It is also used by employees during open enrollment who elect to increase their Supplemental Life Insurance by more than one level.
Life Insurance Evidence of Insurability Form

This form is used by employees during open
enrollment who wish to enroll in Dependent Life
Insurance or Supplemental Life Insurance, or
increase their current Supplemental Life Insurance
by more than one level.
MVP Enrollment Application/Change Form

This form is used to enroll or make changes to your information with MVP.
Prescription - Medco Direct Reimbursement Claim Form

This form should be used by employees of Local 200United who are participants in the healthcare plan provided by 1199, who paid for their prescription, and are requesting reimbursement from Medco (Pharmacy Provider).  It can also be used as a coordination of benefit form if the employee's covered dependent also has prescription coverage elsewhere.
Prescription - NMHCRx Mail Order Form

This form should be used by employees and retirees, or their dependents under the age of 65, who are participants in the Skidmore College PPO Plan to fill their prescription coverage through mail order.  Mail order prescriptions are for a 90 day supply with the copay equivalent to 2 retail copays, saving one month copay.
Prescription - NMHCRx Direct Claim Form

This form should be used by employees and retirees, or their dependents under the age of 65, who are participants in the Skidmore College PPO Plan for reimbursement of any eligible prescription drug costs paid in full out-of-pocket.
Prescription - FOR RETIREES - Caremark Mail Order Form

This form should be used by retirees who are at least age 65, and long-term disability participants who are covered by Medicare, who are covered through the Blue Shield of NENY PPO Plan for medical benefits and SilverScript for their prescription drug coverage.  Mail order prescriptions are for a 90 day supply with the copay equivalent to 2 retail copays, saving one month copay.

Spending Account Reimbursement Form

Health Care and Dependent Care Spending Account Reimbursement Form 

This form is used by employees to request reimbursement from their Flexible Spending Accounts (Health Care Spending and Dependent Care Spending) for services incurred.

Supplemental Retirement Account - Salary Reduction Form

This form is used by employees who wish to enroll in a Supplemental Retirement Account (SRA) or change the amount of their contributions. Changing fund selection/allocation must be done through the company you have selected for your SRA.
Vanguard Address Change Form

This form is to be used when you wish to change your address for your Vanguard Retirement Account.  Please complete, sign and return the form to Human Resources.
Vanguard Beneficiary Change Form

This form is to be used when you wish to change your beneficiary for your Vanguard Retirement Account.  Please complete, sign and return the form to Human Resources.