Human Resources and Office of Institutional Equity
Benefit Forms
Dental :
- Delta Dental Claim Form
- Anthem Dental Complete Form not available
Medical and Prescription:
- Anthem Medical Claim Form
- Anthem Continuation of Insurance for Disabled Children Form
- Express Scripts Mail Order Form
- Express Scripts Rx Claim Form
- Tobacco User Certification Form (PDF)
Flexible Spending Account (FSA):
- PayFlex FSA Claim Form
- Reimbursement Claim Form Instructions
- Letter of Medical Necessity Form
- Direct Deposit Form
Health Savings Account (HSA):
- Account Closure Form
- Beneficiary Designation Form
- Contribution Form
- Enrollment Verification Form
- Request for Return of Excess Contributions
- Trustee Transfer Form
Leaves:
Business and Personal Leaves
- Request for Absence- Non-FMLA (Form 33 Excel)
- Request for Absence- Non-FMLA (Form 33 PDF)
- Military Leave, Outside Activity Leave Paid Parental Leave, and Unpaid Personal Leave (Form 33)
- Leave Action Form for Business Office use only
- Request and Leave Action Form (RLA) for Sabbatical, Research/Instructional/Engagement Travel, Outside Activity Leave or Change in Duty Station (Excel)
Family and Medical Leave Act (FMLA) Forms
- Please contact Vanessa Mettler at 481-6684
- Employee Information Sheet
- Record of Leave for Monthly-paid Employees, "Form 33FMLA"
Retirement:
Vision:
2101 E. Coliseum Blvd.
Fort Wayne, IN 46805
260-481-4739 (IPFW)
Fort Wayne, IN 46805
260-481-4739 (IPFW)
© 2017 Indiana University–Purdue University Fort Wayne (IPFW). All rights reserved. IPFW is an Equal Opportunity/Equal Access University.
If you have trouble accessing this page because of a disability, please email Human Resources and Office of Institutional Equity at accessibility@ipfw.edu.