Human Resources Forms

Medical Benefits Claim 
Instructions and claim form for medical 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

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 (DEI)
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 six months.

TRIP Application
Application for reduction in tuition for spouses and dependents of eligible employees.

Supplemental Retirement Account (SRA) Form 
Contribute funds to TIAA or Fidelity via payroll deduction.

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.

TimeClock Plus User Request Form

Use to give an employee access to maintain a department's TimeClock Plus employees and/or approve time.

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

Department Timekeeper/Contact Google Form
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 03/1/2022)
Use for any change that affects the status of employment.

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 03/25/2020)
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.

Staff Position Authorization - Print on blue paper. (Last revised 03/25/2020)
Use to authorize a new position.

Faculty Position Authorization - Print on blue paper.
Use to authorize a new position.

Form II-A: Search Committee Approval

Form II-B: Advertising Placement Summary

Employee Status Change - Print on gold paper. (Last revised 03/1/2022)
Use for any change that affects the status of employment.

Short Term/Casual/Seasonal Employment Authorization Form - Print on green paper. (Last revised 03/30/2020)

Separation/Transfer Checklist
Use for employee off-boarding.

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.

Faculty Application

Application for Employment - Adjunct Faculty

Temporary Application

Postdoctoral Research Fellow/ Staff Application

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 and 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.

Confidentiality Statement

Bonus Form

Bonus Job Aid

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

AFSCME Bonus Form

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

POA Bonus Form

POA Bonus Request Job Aid

UAW Bonus Form

UAW Bonus Request Job Aid

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.

Bonus Form

Faculty Position Authorization - Print on blue paper. 
Use to authorize a new position.

Employee Status Change - Print on gold paper. 
Use for any change that affects the status of employment.

Affiliated Faculty Appointment Request (Form A1)

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

• Faculty Qualifications Assurance Form

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

Intent to Separate (Resignation/Retirement) - Web form

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 beneficiaries 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

Enrollment Forms

J-1 Scholars Enrollment Form

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 Program Notice

2022 Husky Health Checklist
Complete checklist items between January 1 and December 31, 2022 to earn up to $450!

2022 Retiree Husky Health Checklist
Complete a Blue Cross Blue Shield Michigan Health Assessment and an Annual Physical between January 1 and December 31, 2022 to earn the $200 incentive!

Independent Contractor Questionnaire

Human Resources Banner and Report Access Request Form

Visitor ID & Access Request Form