Loyola University Chicago

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Benefits Forms

• Benefits Selection Form - Lakeside Campuses (PDF)
• Benefits Selection Form - Stritch School of Medicine (PDF)
• BlueCross Claim Form (PDF)
• Delta Dental Claim Form (PDF)
• HMO IL Medical and Guardian/First Comm Dental Provider Selection Form (PDF)
• FSA Reimbursement Request Form (PDF)
• LDA Certification Form (PDF)
• VSP Claim Form (PDF)
• PPO and HMO Illinois Mail Service Order Form (Completed by Patient) (PDF)
• PPO and HMO Illinois Mail Service Order Form (Completed by Physician) (PDF)

Bias Incident Report Form

• Bias Incident Report Form

Change of Address Form

• Change of Address Form

Change of Name

• (Please contact the Human Resources department)

Confidentiality Agreement Form

• Confidentiality Form (PDF) 

Conflict of Interest Disclosure Form

• Conflict of Interest Disclosure Form (PDF)
• Conflict of Interest Policy

Direct Deposit Form

• Direct Deposit Form (PDF)

Disciplinary Report Form

• Disciplinary Report of Conference (PDF)
• Policy on Progressive Discipline   

Family Medical Leave Act (FMLA) Forms

• Request for FMLA (PDF)
• Healthcare Provider Certification (PDF)
• Healthcare Provider Return to Work Certification (PDF)
• FMLA Policy

Giving To Loyola Payroll Deduction Forms

• Payroll Deduction Form
• Faculty and Staff Giving to Loyola Brochure (PDF)

Government Forms

• Federal I-9 Employment Eligibility Form (PDF) 
• Federal W-4 Form (PDF)
• Illinois Dept. of Revenue-Electronic Filing
• Illinois W-4 Form (PDF)    
• Statement of Non-Residence in Illinois

International New Hires   

• Office of International Students & Scholars
• Foreign National Information Form

Leave of Absence Forms

• Request for LOA (PDF)
• LOA Policy

New Hire Forms

• New Employee Packet (PDF)
• Personal Action Form (Formatta)
• Register for Loyola Alert
• International New Hires

Online Employment Applicant System

• Employment Applicant System (Hiring Officials Only)

Pay and Holiday Calendar

• 2009 Pay and Holiday Calendar (PDF)
• 2010 Pay and Holiday Calendar (PDF)

Performance Improvement Form

• Perfomance Improvement Form (PDF)
• Perfomance Improvement Form (Word)

Personal Action Forms (PAF)

• Personnel Action Form (Formatta)
• Student Termination Form (Formatta)    

Retiree Forms

• Blue Medicare Rx Enrollment Form
• Information Update Form
• Retiree Computing & Confidentiality Agreement Form (PDF)
• Retiree Health Account Reimbursement Claim Form
• Retiree Medical Plan Enrollment Form  
  

Retirement Forms

• LUERP Estimate Request Form
• LUERP Beneficiary Form

Short Term Disability

• Short Term Disability Instructions
• Short Term Disability Application (PDF)
• Short Term Disability Return to Work Notification (PDF) 

Tuition Benefit Forms and Information

• FAFSA
• Tuition Benefit Requisition (Formatta)
• Tuition Benefit Requisition (PDF)
• Tuition Benefit Policy and Information 

University Housing Program

• Application
• University Assisted Housing Program Information 

Worker’s Compensation

• Limitations Form (PDF)
• Report of Injury (Formatta)
• Worker’s Compensation Policy and Information