Benefits Forms

North Carolina A&T
Human Resources

Information

Department of Human Resources

1020 E. Wendover Avenue

Suite 101

Greensboro, NC 27411

(336) 334-7862

The following are links to Human Resources-Benefits forms.
Click on the form name to download.

Form Name	Format
OSHA's Form 301 - Injuries and Illness Incident Report	PDF
Earned Income Credit Advance Payment Certificate (W-5)	PDF
Faculty Illness Forms	PDF
Human Resources Clearance Form (PD-201-R)	PDF
Human Resources Clearance Form (PD-201-R) Instructions	PDF
Employee Withholding Allowance Certificate - Federal (W-4)	PDF
Employee Withholding Allowance Certificate - North Carolina (NC-4)	PDF
Employee and Supervisor's Step-by Step Guide to Family and Medical Leave/Military Family Medical Leave	PDF
Family and Medical Leave/Shared Leave Application	Word
Family and Medical Leave - Certification by Medical Practitioner	PDF
Fitness for Duty Certification	Word
Voluntary Shared Leave Application for EPA Employees	Word
Voluntary Shared Leave Application for SPA Employees	Word
Voluntary Shared Leave Donation	Word
*Disability*
The Standard Long Term Disability Enrollment & Change Form	PDF
The Standard Medical History Statement - Late Entrant	PDF
The Standard Long Term Disability Claim Form	PDF
*Health*
Health Insurance Portability & Accountability Act (HIPPA) Authorization	PDF
Health Insurance Portability & Accountability Act (HIPPA) Authorization - Instructions	PDF
State Health Plan Change Form	PDF
State Health Plan Claim Form	PDF
State Health Plan Enrollment Form	PDF
State Health Plan Enrollment Form - Instructions	PDF
Prescription Drug Claim Form	PDF
*NCFlex*
AD&D Beneficiary Designation Form	PDF
AD&D Portability & Conversion Form	PDF
Cancer Claim Form	PDF
Cancer Conversion Form	PDF
Dental Claim Form	PDF
Dental Claim Form - Ameritas	PDF
Dental Claim Processing Guide	PDF
Election of Insurance Continuation Form - Ameritas	PDF
Enrollment Form	PDF
FSA Convenience Card Claim Form	PDF
FSA Convenience Card Enrollment Form	PDF
FSA Convenience Card Dependent Card Request Form	PDF
Group Enrollment/Change or Waiver Form (English) - Ameritas	PDF
Group Enrollment/Change or Waiver Form (Spanish) - Ameritas	PDF
HIPAA Authorization Form	PDF
Spending Account Claim Form	PDF
Status Change Form	PDF
Supplemental Medical Claim Form	PDF
Term Life EOI Form	PDF
Term Life Death Claim Form	PDF
Term Life Beneficiary Form	PDF
Term Life Continuation Form	PDF
*Retirement*
Optional Retirement Plan Enrollment Form (ORP-1)	PDF
Optional Retirement Plan Change Form (ORP-2)	PDF
Optional Retirement Plan Acknowledgment for Disposition of Account Contributions (ORP-3)	PDF
Optional Retirement Plan Authorization for Coverage Under the State of NC Retired Group Health Plan (ORP-4)	PDF
State Retirement System Application for Refund of Retirement Contributions (Form 5)	PDF
State Retirement System Application for Retirement (monthly benefits) (Form 6)	PDF
State Retirement System New Member Enrollment Application (Form 2)	PDF
State Retirement System Notice of Change of Beneficiary (active members) (Form 2C)	PDF
Teachers' and State Employees Comprehensive Major Medical Plan, Retired Group Enrollment/Change Form (Ret HM)	PDF
*403(b)*
The North Carolina A&T Authorization for 403(b) Salary Reduction Agreement	Word
*Worker's Compensation*
NC A&T Accident Report Package	PDF
North Carolina Industrial Commission Employer's Report of Injury to Employee (Form 19)	PDF

Estimate Your Retirement Benefits (TSERS)

State Health Plan 2004 Benefit Book

HIPAA Privacy Notice

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