Forms For Hartwick Employees

All forms are pdf documents and are available from the links below for downloading. To download a pdf document you'll need Adobe Acrobat Reader; download a free copy of the reader here.

Medical/Dental Forms:

2015-16 Medical/Dental Rates
CDPHP Enrollment/Change Form
CDPHP PPO Summary of Benefits and Coverage
CDPHP EPO Summary 
CDPHP EPO Summary of Benefits and Coverage
CDPHP HDEPO Summary of Benefits and Coverage

Health Savings Account (HSA) Salary Reduction Form- 2015

CDPHP Caremark Pharmacy Mail Order Form
CDPHP RX for Less Program 
CDPHP Reimbursement Claim Form

MVP Gold Anywhere PPO Summary 2015
USA Care PPO Summary 2015
MVP Medicare Advantage Plan Enrollment Form

ComTon Dental Plan Summary
ComTon Dental Enrollment/Change Form
Dental Claim Form
Dental Student Waiver Form
ComTon Authorization for Release of Information

Aflac Enrollment Application
Aflac Specific Disease Plan, Level 3

COBRA Notice

Domestic Partner Affidavit

Family and Medical Leave Request Form

New York State Short-Term Disability Claim Form and Statement of Rights

Payroll Related Forms:

Federal I-9 Verification Form

Federal W-4 Withholding Form

NYS Withholding Form IT-2104
NYS Withholding Exemption Form IT-2104E

Authorization of Direct Deposit Form

403(b) Retirement Accounts

TIAA-CREF Microsite for Online Enrollment
TIAA-CREF Salary Reduction Form

Fidelity Contribution Enrollment Form
Fidelity Salary Reduction Form

Flexible Spending:

Flexible Spending Account Election Form and Rules & Claim Filing Info- Plan Year 2015-16
Flexible Spending Account Claim/Reimbursement Form 
Flexible Spending Direct Deposit Enrollment Form
ComTon Authorization for Release of Information Form

Human Resources Related Forms:

Background Check Form

Employment Application Form

Ethnicity Information Form

Information Technology Responsible User Policy & Form

Horizon Employee Assistance Program

Job Analysis Questionnaire PDF

Job Analysis Questionnaire (MS-Word Fill-In Form)

Life Insurance Enrollment/Beneficiary Change Form

EEO Exempt Employee Search Report Form
EEO Non-Exempt Employee Search Report Form

Tuition Exchange Eligibility and Request Form
Tuition Remission Eligibility and Request Form

Worker's Compensation Forms:

Incident Report Form
Release of Information Form

Employee Evaluation Forms:

Performance Appraisal for Supervisory Staff MS InfoPath

Performance Appraisal for Exempt Staff MS InfoPath

Performance Appraisal for Non-Exempt Staff MS InfoPath