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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 NameDatedInstructions
or Information		 Versions
Accident/Injury Report (PER-17) (Workers' Compensation) 07/2009 PPM 4820.100 RTF Word PDF  
Application for President's Scholarship (PER-32A) 01/2007 PPM 4870.40 RTF Word PDF  
Application for Tuition Assistance 2009/2010       PDF 
Beneficiary Designation (KPERS-7/99) 07/2006 PPM 4820.60    PDF 
Designation of Beneficiary (KPERS-7/99) 07/2006 PPM 4820.60    PDF 
Documentation of Service for Immediate Participation in Regents Retirement Program (PER-33) 01/2007 PPM 4810.20 RTF Word PDF 
Educational Authorization Form (PER-25) 5/1998 PPM 4870.20 RTF Word PDF 
Flexible Spending Claim Form 2010 Flexible Spending Accounts     PDF
Flexible Spending Account Direct Deposit/E-Mail Notification Form   Flexible Spending Accounts   Word   
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 2008/2009 Information     PDF  
Health Care Selection Form 06/2003 Health Insurance     PDF  
Health Insurance Affidavit of Common Law Marriage and Request for Enrollment of Common Law Spouse 08/2009 Health Insurance     PDF  
Health Insurance Application for Coverage of Handicapped Dependent Child 02/2008 Health Insurance     PDF  
Health Insurance Communication Form 08/2009 Health Insurance     PDF 
Health Insurance Dependent Grandchild Affidavit 07/2009 Health Insurance     PDF  
HIPAA- Authorization Form for Release of Medical Information 03/2008 Health Insurance     PDF  
Health Savings Account Enrollment & Change Form 08/2009 Health Insurance     PDF  
HealthyKIDS Application   Information(pdf)      Online
Investment Agreement - Mandatory Retirement Plan (Kansas Board of Regents) (PER-13) 01/2007 PPM 4810.20 RTF Word PDF  
Investment Agreement - Voluntary Retirement Plan(PER-19) 11/2008 PPM 4810.80 RTF Word PDF  
Kansas Board of Regents Mandatory Retirement Plan Investment Agreement (PER-13) 01/2007 PPM 4810.20 RTF Word PDF  
Learning Quest Direct Investment Form Information    PDF 
Learning Quest Payroll Deduction Change 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 12/2007 PPM 4070 RTF Word PDF 
Orientation Forms Checklist 11/2001 PPM 4070 RTF Word PDF  
Prescription Claim Form   Prescription Drug Program     PDF  
Prescription Drug Advance Purchase Certificate 03/2008 Advance Purchase Policy(pdf)     PDF  
President's Scholarship Application (PER-32A) 01/2007 PPM 4870.40 RTF Word PDF  
Retirement Notification (PER-37) 6/2009 PPM 4810 RTF Word PDF  
Retirement Plan Investment Agreement - Mandatory (Kansas Board of Regents) (PER-13) 01/2007 PPM 4810.20 RTF Word PDF  
Retirement Plan Investment Agreement - Voluntary(PER-19) 11/2008 PPM 4810.80 RTF Word PDF  
Savings Bond Payroll Savings Authorization (PER-14) 01/2007 U.S. Savings Bonds RTF Word PDF  
Shared Leave Donation Form 8/2001 Classified PPM 4860.140
Unclassified PPM 4865.140		 RTF Word PDF  
Shared Leave Request Form 10/2007 Classified PPM 4860.140
Unclassified PPM 4865.140		 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  
Tuition Assistance Application 2009/2010       PDF 
U.S. Savings Bond Payroll Savings Authorization (PER-14) 01/2007 U.S. Savings Bond RTF Word PDF  
Workers' Compensation Accident/Injury Report (PER-17) 07/2009 PPM 4820.100 RTF Word PDF  
Workers' Compensation Mileage Reimbursement Form   Information RTF Word PDF