HR Forms Library

Human Resources Forms

• Adoption Reimbursement Form
• Alternative Work Arrangements Form (pdf)
• Beneficiary Designation (Retired Employee Death Benefit)
• Beneficiary Form (Defined Benefit Retirement Plan)
• Beneficiary Form (Group Term Life Insurance and College Travel Accident Insurance)
• Family Medical Leave Application
• Family Medical Leave Medical Certification Form (Employee)
• Family Medical Leave Medical Certification Form (Family Member)
• Fitness Reimbursement Benefit Form
• Health Care Cost Hardship Application
• Hybrid/Remote Work Agreements for Staff (requires Dartmouth Single Sign-on)
• Leave of Absence From (Unpaid) (pdf)
• Leave of Absence Form (Hiatus) (pdf)
• Name and Address Changes (Payroll Office)
• Paid Parental Leave Application
• Performance Evaluation Forms
• Status Changes (Mid year Qualifying Event)
• Tuition Benefits Forms
  • Employee Status Verification Form for Grant-in-Aid Benefits
  • Graduate Tuition Benefits Form
  • Tuition Assistance Request
• Waive Amortization Form (Hiatus) (pdf)

Payroll Authorization Forms and Employee Information Forms (for Direct Deposit, Name Changes, Address Changes, etc.) are available on the Payroll Forms website.

Federal Forms

• I-9 Form

Provider Forms

The following forms are available via links to the providers' Web sites. Navigation instructions are listed below.

• Retirement Fund Forms
  • 457(b) Election Form
  • Beneficiary, Designation of (Fidelity Investments)
    • Log in to NetBenefits.
    • Click on "Your Profile".
    • Click on "Beneficiaries."
  • Beneficiary, Designation of (TIAA)
    • Scroll down to "Adding/Changing Your Beneficiary" on the left.
    • In the "Designating Beneficiaries" box, "Complete Online".
• Delta Dental Forms
  • Northeast Delta Dental Claim Form (PDF Form)
• Cigna Forms
  • Medical - Claim reimbursement form
  • Mental Health - Claim reimbursement form
  • Vision - Claim reimbursement form
  • Provider Nomination Form
  • Cigna Appeal Request Form
  • Dual Coverage Form (Employee covered under multiple plans)
  • Cancel Dual Coverage Form
  • Disabled Dependent Form
• Life Insurance Forms
  • SEIU Beneficiary Form
• Flexible Spending Account Forms (Submit to WageWorks until 12/14/20, submit to Sentinel after 1/1/21)
  • Sentinel HCFSA Claim Form (PDF Form)
  • Sentinel DCFSA Claim Form (PDF Form)
• Prescription Drug Forms
  • Express Scripts Claim Form
  • Prescription Mail Order Form
• Dartmouth College Medicare Supplement (DCMS) and Retiree Forms
  
  • Express Scripts Medicare Part D claim form
  • Retired Employee Death Benefit Beneficiary form (for individuals who retired from Dartmouth on or before 12/31/2010)