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

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.

This form is used to designate the funds for the Skidmore College Basic Retirement Plan.

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

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.

This form is used to enroll or make changes to your information with the Skidmore College PPO Plan.

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

This form is used to submit dental claims to the provider.

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

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

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

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

This form is used to remove a Domestic Partner, if you selected Domestic Partner Coverage

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.

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

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.

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.

This form is used by Skidmore Employees to request leave covered by the Family and Medical Leave Act.

Flexible Spending Account Forms
     Health Care Reimbursement Form (2011)
     Dependent Care Reimbursement Form (2011)

These forms are used by employees to request reimbursement from their Flexible Spending Accounts (Health Care Spending and Dependent Care Spending) for services incurred.  If you are submitting a claim against your 2011 Flexible Spending Account election use the Rose & Kiernan forms above.

If you are submitting a claim against your 2010 Flexible Spending Account election use The Preferred Group form below.  The Preferred Group will accept claims through the end on March 2011.
     Preferred Group Reimbursement Voucher (2010)

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

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

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.

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.

This form is used to enroll or make changes to your information with MVP.

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.

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.

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.

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.

This form should be used by retirees and long-term disability participants who are Medicare eligible and are covered through Blue Shield of NENY for their medical bills and SilverScript for their prescription drug coverage.  There may be times when you will need prior authorization to receive a specific drug.

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.

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.

This form is to be used for anyone who has left employment and is requesting a distribution or rollover to another account.

This form is to be used for anyone who has left employment and is requesting income in the form of installment payments.  This form is to be used in conjunction with the Vanguard Distribution Form.