Benefit Form Library: Office of Faculty and Staff Benefits

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Benefit Form Library

The Benefits Office is pleased to provide you access to the forms listed below so you do not have to come to our office, or call us, merely to obtain a form. It is not intended for you to be able to complete any of these forms on-line.
 

You will need Adobe Acrobat Reader© to view these forms. If you do not have Adobe Acrobat Reader software on your computer, simply click >> here << to get the free software from Adobe and follow the installation instructions.
 

Medical Forms

Carefirst BlueChoice Enrollment Form
Carefirst BlueChoice Claim Form
CareFirst/Walgreens Prescription Drug Mail Order Form
CareFirst/Argus Prescription Direct Reimbursement Form
CareFirst BlueChoice Student Certification Form
 

Kaiser Permanente Enrollment Application & Change Form

Aetna Open Choice Enrollment/Change Form
Aetna Open Choice Claim Form
Aetna Rx Home Delivery Order Form

United Healthcare Choice Plus Enrollment/Change Form
United Healthcare Choice Plus Claim Form
United Healthcare/Medco Prescription Reimbursement Form
United Healthcare/Medco Prescription Mail Order Form 
 

Dental Forms

Delta Dental Enrollment/Change Form   (Standard & Enhanced)
Delta Dental Claims Form

Aetna US Healthcare DMO Enrollment/Change Form
 

CareFirst Dental Claims Form (for services received on or before December 31, 2009)

 

 Vision Forms

 

EyeMed Vision Care Enrollment/Change Form
 

 EyeMed Vision Care - Out-of-Network Claim  Form

Legally Domiciled Adult 

LDA Enrollment Form

Termination of LDA Status Form

Retirement Forms

Salary Reduction Agreement Form 

Georgetown University Retirement Plan (GURP) Benefit Application & Calculation Request Form

Beneficiary Designation Form for Pre-Retirement Death Benefit (GURP)

Beneficiary Designation Form for Co-Annuitant/Post-Retirement Death Benefit (GURP)

Life Insurance Forms

MetLife Statement of Health Form

Enrollment Form (for newly hired employees/open enrollment elections)

Flexible Spending Account Forms

Flexible Spending Account Enrollment Form
Flexible Spending Account Claim Form
Flexible Spending Account Direct Deposit Authorization  

Tuition Assistance Program (TAP) Forms

We strongly recommend that you apply for TAP benefits online. However, if you do not have a Net ID and password, you can obtain a TAP form below.

Faculty/AAP/Staff Attending GU
Faculty/AAP/Staff Attending Outside Institutions
Child Attending GU
Child Attending Outside Institutions
Application for Tax-free Graduate TAP Benefits 


 

Office of Faculty and Staff Benefits · Georgetown University
37th & O St NW, Ground Floor, Healy Hall · Washington, DC 20057-1021
tel. (202) 687-2500 · fax. (202) 687-2389 ·
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