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 ClaimInstructions and claim form for medical insurance benefits for covered services received outside the U.S., Puerto Rico and the U.S. Virgin Islands.
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 within 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.
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 Application
Yearly application for 50% reduction in tuition for spouses and dependents of eligible
employees.
Supplemental Retirement Account (SRA) Form
Contribute funds to TIAA or Fidelity via payroll deduction.
Voluntary Accidental Death and Dismemberment Enrollment
Beneficiary designation and request to participate or waiver of insurance.
Payroll Services
Payroll Services Forms
Certificate of Non-Residency
For employees working in Michigan who are residents of Illinois, Indiana, Kentucky,
Minnesota, Ohio or Wisconsin.
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.
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.
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.
Department Contact Information
Use this form to be added as a department contact for payroll related information
and communications.
Payroll Related Forms (Please contact the appropriate department with questions)
Beneficiary Designation Form
Designate payment of all earned compensation at death by completing this form. It
can also be completed on Banweb.
Employee Status Change - Print on gold paper - (Last revised 4/28/2015)
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.
I-9 Employment Eligibility Verification Form
Links to www.uscis.gov site.
Position Authorization - Print on blue paper - (Last revised 01/28/2015)
Use to initiate a new position.
Supplemental Retirement Account (SRA) Form
Used to select contribution amounts for 457(b) or 403(b) retirement plans.
Temporary Employee Authorization Form - Print on green paper - (Last revised 4/28/2015)
Used to authorize a temporary position.
Employment and Hiring Forms
Position Authorization - Print on blue paper. (Last revised 06/16/2017)
Use to authorize a new position.
Employee Status Change - Print on gold paper. (Last revised 09/22/2016)
Use for any change that affects the status of employment.
Short Term/Casual/Seasonal Employment Authorization Form - Print on green paper. (Last revised 4/28/2015)
Separation/Transfer Checklist
Use for employee off-boarding.
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.
Forms for New Employees
Staff On-Boarding Checklist
Designed to assist new and transferring employees in completing all essential paperwork
and to support integration into a new role at Michigan Tech.
Beneficiary Designation
Designates payment of all earned compensation at death. It can also be completed
on Banweb.
Board of Trustees 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)
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.
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 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.
Forms for Faculty
Employee Status Change - Print on gold paper. (Last revised 4/28/2015)
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 06/16/2017)
Use to authorize a new position.
Intent to Separate (Resignation/Retirement) - Web form
Retirement Forms
Supplemental Retirement Account (SRA) Form
Used to select contribution amounts for 457(b) or 403(b) retirement plans.
RSVP Beneficiary Designation
Designate primary and contingent beneficiates 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
Enrollment Forms
Payroll Deduction and Waiver Forms
Graduate and International Student Waiver Request
Waive Michigan Tech Student Health Insurance by providing information documenting
comparable existing coverage.
J1 Scholar Waiver Request
Waive Michigan Tech J1 Scholar 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.