Human Resources Forms

Benefits Claims Forms

Medical Benefits Claim 
Instructions and claim form for medical insurance benefits.

Prescription Drug Claim 
Instructions and claim form for prescription drug insurance benefits.

International Medical Claim
Instructions and claim form for medical insurance benefits for covered services received outside the U.S., Puerto Rico and the U.S. Virgin Islands.

Athlete Claim 
Health insurance claim form for student athletes covered under Michigan Tech's Aetna plan.

Flexible Spending Claim Form 
Reimbursement request for itemized eligible expenses.

Long Term Disability Claim - Employee Statement

Long Term Disability Claim - Medical Disclosure Authorization

Long Term Disability Claim - Physician's Statement

Short Term Disability Claim

Other Benefit Services Forms

HSA Deposit Slip
Use for non-payroll deductions Health Savings Account deposits.

COBRA Continuation Coverage Election
Must be submitted withing 60 days from date of notice of insurance termination.

Designated Eligible Individual Enrollment
Must be completed during regular TechSelect open-enrollment period or no more than 30 days after all criteria are met.

Healthcare Audit Reward Program (HARP) Form
Use for reporting errors in your EOBs.

Health Enrollment Change
Used to change your health enrollment options outside of open-enrollment due to a change in family status.

HSA Payroll Deduction Contribution Change
Change amount deducted from paychecks and deposited into your Health Savings Account.

Life Insurance Beneficiary Designation
Name primary and contingent beneficiaries for Michigan Tech Life Insurance plans.

Property Listing Application
Applications for listings will be kept on file no longer than 6 months.

TRIP Policy and Application
Yearly application for 50% reduction in tuition for spouses and dependents of eligible employees.

Voluntary Accidental Death and Dismemberment Enrollment
Beneficiary designation and request to participate or waiver of insurance.

Payroll Services Forms

Payroll Services Forms

Approver Change Form 
Used to change approvers for Electronic Time Entry on Banweb.

Compensatory Time Record 
Used to maintain a record of an employee's compensatory time balance.

Beneficiary Designation Form 
Designate payment of all earned compensation at death by completing this form.  It can also be completed on Banweb.

Deferred Pay Plan Election 
Elect to be paid for 26 pay periods. This needs to be filled out prior to contract start date.

Direct Deposit Authorization  
Authorize Michigan Tech to deposit money from your paycheck to a financial institution.  Update your Direct Deposit Authorization online using Banweb.

I-9 Employment Eligibility Verification Form 
Links to www.uscis.gov site.

MI-W4 Michigan Income Tax Withholding Form 
Links to www.michigan.gov site. Also check online using Banweb.

Off-cycle Payroll Check Authorization Form 
Use this form to request a payroll check to be issued during the non-payroll week.

Reallocation of Payroll Funds 
Use to reallocate funds from one account to another.

Request for Account Distribution Change 
This has been replaced with an EPAF.  Click the link for instructions.

Time Sheet 
Fill in on the web.

W-4 Federal Income Tax Withholding Form 
Links to www.irs.gov site. Also check online using Banweb.

Payroll Related Forms (Please contact the appropriate department with questions)

Employee Status Change - Print on gold paper - (Last revised 5/08/2013)
Use for any change that affects the status of employment.

Graduate Student Health Insurance Payroll Deduction Authorization 
Authorizes money to be deducted from your paycheck to pay Graduate Student Health Insurance.

HSA Payroll Deduction Contribution Change 
Change amount deducted from paychecks and deposited into your Health Savings Account online using Banweb.

Position Authorization - Print on blue paper - (Last revised 11/13/2013)
Use to initiate a new position.

Retirement Salary Reduction Agreement (SRA) 
Used to select contribution amounts for 457(b) or 403(b) retirement plans.

Student Requisition/Status Change - use EPAF  
Use to extend employment, change pay rate, switch destination of check to new department, and to cease pay.

Temporary Employee Authorization Form - Print on green paper - (Last revised 11/13/2012)
Used to authorize a temporary position.

Hiring Resources Forms

Forms for Departments

Position Authorization - Print on blue paper. (Last revised 11/13/2013)
Use to authorize a new position.

Employee Status Change - Print on gold paper. (Last revised 5/08/2013)
Use for any change that affects the status of employment.

Temporary Employee Authorization Form - Print on green paper. (Last revised 11/13/2012)

Forms for New Employees

Beneficiary Designation 
To be filled out by a new employee.  Designates payment of all earned compensation at death.  It can also be completed on Banweb.

Board of Control Policy for At Will vs. Satisfaction Employment Relationship (non-union staff only)
Indicate the selected employment status by signing the Acknowledgment Form on the last page.

Direct Deposit Authorization 
To be filled out by a new employee.  Authorizes Michigan Tech to deposit money from your paycheck to a financial institution.  Update your Direct Deposit Authorization online using Banweb.

Emergency Notification Form 
Designate who should be contacted in the event of an emergency.

Employee Patent, Research, and Proprietary Rights Agreement 
New employees sign this form to indicate that you have read both sides and understand the agreement.  Also for graduate students.

I-9 Employment Eligibility Verification 
Used to document that each new employee is authorized to work in the United States.

MI-W4 Michigan Income Tax Withholding Form
Links to www.michigan.gov site.  Also check online using Banweb.

New Employee Information Expectations 
Indicate compliance with all University policies and regulations by reviewing and signing this form.

W-4 Federal Income Tax Withholding Form
Links to www.irs.gov site.  Also check online using Banweb.

Immigration Forms

Job Application Forms

When applying for any non-union, staff position, you must submit all application materials electronically by setting up an account at Michigan Tech Jobs and following the instructions to apply.

EEO Form

Faculty Application

Staff Application

Temp Application

Forms for New Employees

Beneficiary Designation 
Designates payment of all earned compensation at death.  It can also be completed on Banweb.

Board of Control Policy for At Will vs. Satisfaction Employment Relationship (non-union staff only)
Indicate the selected employment status by signing the Acknowledgment Form on the last page.

Direct Deposit Authorization 
Authorizes Michigan Tech to deposit money from your paycheck to a financial institution.  Update your Direct Deposit Authorization online using Banweb.

Emergency Notification Form 
Designate who should be contacted in the event of an emergency.

Employee Patent, Research, and Proprietary Rights Agreement 
New employees sign this form to indicate that you have read both sides and understand the agreement.  Also for graduate students.

I-9 Employment Verification Form
Links to www.uscis.gov site.

MI-W4 Michigan Income Tax Withholding Form
Links to www.michigan.gov site.  Also check online using Banweb.

New Employee Information Expectations 
Indicate compliance with all University policies and regulations by reviewing and signing this form.

W-4 Federal Income Tax Withholding Form
Links to www.irs.gov site.  Also check online using Banweb.

Forms for Staff (Non-union)

Bonus Request Form

Information Technology Reclassification Form 
Word document version of the reclassification form for Information Technology employees.

Information Technology Reclassification Form 
.pdf version of the reclassification form for Information Technology employees.

Request to Examine Personnel Records

Forms for Staff (Union)

AFSCME Grievance Form 
Used to initiate the grievance process.

AFSCME Reclassification Form 
Position Documentation Questionnaire for initiating the reclassification process.

Request to Examine Personnel Records

UAW Bonus Request Form

UAW Checkoff for Representative 
Used to selected representation preference for disciplinary meeting.

UAW Flextime Application 
Used to request an alternative work scheduling arrangement.

UAW Grievance 
Fill out this form to begin the grievance process.

UAW Performance Evaluation Request 
Used to agree or disagree to a specific performance evaluation.

UAW Position Audit Form and Guide 
Position audit for UAW job reclassification.

Academic Human Resources Forms

Employee Status Change - Print on gold paper. (Last revised 5/08/2013)
Use for any change that affects the status of employment.

Faculty Appointment Recommendation (Form A)
Use to appoint faculty.

Full Off-Semester (Summer) Appointment Request and Certification Form 
Apply for additional compensation for full off-semester (summer).

Position Authorization - Print on blue paper. (Last revised 11/13/2013)
Use to authorize a new position.

Intent to Separate (Resignation/Retirement) - Web form

Retirement Forms

Retirement Salary Reduction Agreement (SRA) 
Used to select contribution amounts for 457(b) or 403(b) retirement plans.

RSVP Beneficiary Designation 
Designate primary and contingent beneficiaties for the Retirement Supplemental Voluntary Program.

RSVP Election Form 
Sign up to participate in the Retirement Supplemental Voluntary Program.

RSVP Health Insurance Waiver 
After enrolling in RSVP, use this form to opt out of the University's health insurance program if you have alternate insurance.

RSVP Phased Retirement Option Agreement 
Choose the phased retirement option or the combined monetary/phased retirement option.

Faculty Intent to Separate (Resignation/Retirement) - Web form

Student Health Insurance Forms

Athlete Claim Form 
Health insurance claim form fore student athletes covered under Michigan Tech's Aetna plan.

Athlete Enrollment 
Aetna enrollment form for student athletes.

Supported Graduate Student Enrollment 
Aetna enrollment form for supported graduate students.

Supported Graduate Student Payroll Deduction Authorization 
Authorizes money to be deducted from your paycheck to pay for Graduate Student Health Insurance.

Unsupported Graduate and Undergraduate Student Enrollment 
Aetna enrollment form for domestic undergraduates, international undergraduates, and unsupported graduate students.

Waiver Request 
Waive Michigan Tech Student Health Insurance by providing information documenting comparable existing coverage.

Wellness Forms

HuskyPAW Points Form 
HuskyPAW Physical Activity & Wellness monthly point tracking form.

HuskyPAW Referral Certificate 
Complete the card to receive 200 HuskyPAW points for each eligible employee you refer to the program.

TechFit Wellness Program Form 
Complete the form and return to the service provider to be submitted to the University with the invoice.  Payment will not be made without this form.

Independent Contractors Forms

Banner Human Resources Access Forms

Visitor ID & Email Request Forms