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Kansas State University

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Technical Support for Forms:
Kathy Kugle (785) 532-1885
or email kkugle@ksu.edu

Forms

Division of Human Resources
Kansas State University
103 Edwards Hall
Manhattan, KS 66506-4801
785-532-6277
785-532-6095 (fax)
8 a.m. - 5 p.m. (CST)
Contact HR

Benefits Forms

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Alphabetical List of Benefits Forms
FORMS by Name Dated Instructions
or Information
Versions
Accident/Injury Report (PER-17) (Workers' Compensation) (do not use after April 30, 2014) 02/2010 PPM 4820.100 RTF Word PDF  
Accident Report (1101-A) (Workers' Compensation) (new form can be used now and will be the only form accepted starting May 1, 2014) 10/2013 PPM 4820.100     PDF  
(Summer) Application for Tuition Assistance (2013) 2013       PDF  
Application for Tuition Assistance 2013/2014       PDF  
Application for Tuition Assistance - Dependents/Spouses 2013/2014 Dependent/spouse grant     PDF  
Beneficiary Basic/Optional Life insurance KPERS employees (KPERS 7/99) 04/2011 PPM 4820.60     PDF  
Beneficiary Basic/Optional Life Insurance Board of Regents employees (KPERS 7/99A) 6/2010 PPM 4820.60     PDF  
Beneficiary TEA optional life insurance Met Life 07/2001 Included
TEA Life Insurance
    PDF  
Documentation of Service for Immediate Participation in Regents Retirement Program (PER-33) 06/2012 PPM 4810.20     PDF  
Educational Authorization Form (PER-25) 5/1998 PPM 4870.20 RTF Word PDF  
Flexible Spending Account Enrollment/Change Form 2014 Flexible Spending Accounts     PDF 
FMLA Certification of Health Care Provider for Employee's Serious Health Condition   FMLA Dept. of Labor     PDF  
FMLA Certification of Health Care Provider for Family Member's Serious Health Condition   FMLA Dept. of Labor     PDF  
FMLA Notice of Eligibility and Rights & Responsibilities   FMLA Dept. of Labor     PDF  
FMLA Designation Notice   FMLA Dept. of Labor     PDF  
FMLA Certification of Qualifying Exigency For Military Family Leave   FMLA Dept. of Labor     PDF  
FMLA Certification for Serious Injury or Illness of Covered Servicemember -- for Military Family Leave   FMLA Dept. of Labor     PDF  
Graduate Research Assistant/Teaching Assistant Health Insurance   Information        
Health Care Selection Form   Health Insurance     PDF  
Health Insurance Affidavit of Common Law Marriage 2013 Health Insurance     PDF  
Health Insurance Application for Coverage of Handicapped Dependent Child 2013 Health Insurance     PDF  
Health Insurance Change Form 2013 Health Insurance     PDF  
Health Insurance Communication Form 2013 Health Insurance     PDF  
Health Insurance Dependent Grandchild Affidavit 2013 Health Insurance     PDF  
Health Insurance Enrollment Form 2014 Health Insurance     PDF  
HIPAA- Authorization Form for Release of Medical Information 2013 Health Insurance     PDF  
Health Savings Account Enrollment & Change Form 2013 Health Insurance     PDF  
HealthyKIDS Application   Information       Online
Investment Agreement - Mandatory Retirement Plan (Kansas Board of Regents) (PER-13) 06/2012 PPM 4810.20     PDF  
Investment Agreement - Voluntary Pre-Tax Retirement Plan(PER-19) 02/2013 PPM 4810.80     PDF  
Investment Agreement - Voluntary Roth After-Tax Retirement Plan (PER-19R) 02/2013 PPM 4810.80     PDF  
Kansas Board of Regents Mandatory Retirement Plan Investment Agreement (PER-13) 06/2012 PPM 4810.20     PDF  
Learning Quest Direct Deposit Change or Enrollment Form   Information     PDF  
Life Insurance Beneficiary Designation Form (TEA) 07/2001 Included
TEA Life Insurance
    PDF  
Life Insurance Enrollment Form (TEA)   TEA Life Insurance     PDF  
Life Insurance Request to Change or Cancel Insurance Policy Form (TEA)   TEA Life Insurance     PDF  
Life Insurance Statement of Health (TEA)   TEA Life Insurance     PDF  
Mileage Reimbursement Form (Workers' Compensation)   Information RTF Word PDF  
New Employee Orientation Forms Checklist 11/2001 PPM 4070 RTF Word PDF  
Notification of Retirement (PER-37) 6/2009 PPM 4810 RTF Word PDF  
Optional Group Life Enrollment Form   Optional Life     PDF  
Optional Group Life Reduction/Cancellation Form 09/2003 Optional Life     PDF  
Orientation Checklist 08/2012 PPM 4070 RTF Word PDF  
Orientation Forms Checklist 11/2001 PPM 4070 RTF Word PDF  
Prescription Claim Form 2012 Prescription Drug Program     PDF  
Retirement Notification (PER-37) 6/2009 PPM 4810 RTF Word PDF  
Retirement Plan Investment Agreement - Mandatory (Kansas Board of Regents) (PER-13) 06/2012 PPM 4810.20     PDF  
Retirement Plan Investment Agreement - Voluntary Pre-Tax (PER-19) 02/2013 PPM 4810.80     PDF  
Investment Agreement - Voluntary Roth After-Tax Retirement Plan (PER-19R) 02/2013 PPM 4810.80     PDF  
Shared Leave Donation Form (PER-64D) 4/2012 Instructions RTF Word PDF  
Shared Leave Request Form (PER-64A&B) 3/2013 Instructions RTF Word PDF  
TEA Life Beneficiary Designation Form 07/2001 Included
TEA Life Insurance
    PDF  
TEA Life Insurance Enrollment Form   TEA Life Insurance     PDF  
TEA Life Insurance Request to Change or Cancel Insurance Policy Form   TEA Life Insurance     PDF  
TEA Life Insurance Statement of Health   TEA Life Insurance     PDF  
(Summer) Tuition Assistance Application (2013) 2013       PDF  
Tuition Assistance Application 2013/2014       PDF  
Tuition Assistance Application - Dependents/Spouses 2013/2014 Dependent/spouse grant     PDF  
Workers' Compensation Accident/Injury Report (PER-17) 02/2010 PPM 4820.100 RTF Word PDF  
Workers' Compensation Accident Report (1101-A) 10/2013 PPM 4820.100     PDF  
Workers' Compensation Mileage Reimbursement Form   Information RTF Word PDF