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BENEFITS FORMS AND INFORMATION

• ‌Benefit Enrollment Status Change Form- New Form Effective January 2013 (Fillable PDF)   
• BlueCross Claim Form (PDF) (PDF)
• Delta Dental Claim Form (PDF)
• Evidence of Insurability (PDF)
• FSA Reimbursement Request Form (PDF) Reimbursement request for 2012 must be submitted to Benefit Express by 3.31.2013
• LDA Certification Form 2012 Form Revised Sept 2012 (PDF)
• VSP Claim Form (PDF)
• BCBS Prescription Drug Information (Website)
• How to order your PrimeMail Presciptions (PDF)
• PrimeMail New Prescription Fax order form (PDF)
• Weight Watchers Reimbursement Form 2013 (PDF)
• Summary of Benefits and Coverage 2013 (PDF)
• 2013 Wellness Incentive Form (PDF)
• Prescription Drug Claim Form (PDF)

Change of Address Form

• Change of Address Form

Change of Name

• Change of Name Form (PDF)

Confidentiality Agreement Form

• Confidentiality Form (PDF)

Conflict of Interest Disclosure Form

• Conflict of Interest Policy

Direct Deposit Form

• Direct Deposit Form (PDF)

Disciplinary Report Form

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

EthicsLine Reporting Hotline

• EthicsLine Reporting Hotline

Family Medical Leave Act (FMLA)

Family & Medical Leaves are now administered by Matrix Absence Management. To intiate a family or medical leave request, or Short-Term Disability, please call Matrix at 1-877-202-0055 or Matrix on-line claims filing at: www.MatrixeServices.com 

•  FMLA Policy

Giving To Loyola Payroll Deduction Forms

• Payroll Deduction Form

Faculty and Staff Giving to Loyola Brochure 

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 Leave of Absence‌  (PDF)
• LOA Policy

New Hire Forms

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

Online Employment Applicant System

• Employment Applicant System (Hiring Officials Only)

Pay and Holiday Calendar

• 2012 Pay and Holiday Calendar  (PDF)
• 2013 Pay and Holiday Calendar  (PDF)

Performance Improvement Form

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

Personnel 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

Transit Benefit Enrollment Form

• Transit Enrollment Form‌

Tuition Benefit Forms and Information

• FAFSA
• Tuition Benefit Policy and Information 

University Housing Program

• Application
• University Assisted Housing Program Information 

Workers' Compensation

• Limitations Form  (PDF)
• Report of Injury  (Formatta) -- Download Formatta Filler 
• Workers' Compensation Policy and Information