Tuition Waiver

• At Millersville
  • Initial Application for Employees (XLS)
  • Initial Application for Dependent/Spouse of Employee (XLS)
    (three forms in one excel spreadsheet; complete the form at each tab)
  • Session Application (XLS)
    
• At Other PASSHE Universities
  • Managers Waiver for Manager/Spouse/Domestic Partner/Dependents (PDF)
  • Faculty Waiver for Faculty Member/Spouse/Domestic Partner/Dependents (XLS)

Faculty Out-Service Training

• Eligibility Requirements and Procedures (DOC)
• Policy Statement 250 (PDF)
• Faculty Out-Service Training Program Agreement (DOC)

Staff Out-Service Training

• Staff Out-Service Training Program (DOC)
• Staff Out Service Training Application (XLS)

Beneficiary Forms

• Prudential Beneficiary Form (PDF)
  To change your beneficiary(ies) for your group life insurance.  Prudential can be reached at 800-893-7316.
• SERS402 beneficiary Form (PDF)
  Beneficiary form for employees enrolled in the State Employees’ Retirement System.
• TIAA-CREF beneficiary form F5519 (PDF)
  Beneficiary form for employees enrolled in TIAA-CREF retirement plan)Group Life Insurance..
• VGLIP Enrollment & Beneficiary Form (PDF)
  If you are enrolled in the Voluntary Group Life Insurance, you may use this form to update your beneficiaries. Complete only the Employee Section and the Beneficiary Section. Sign and date the form, and return it to Human Resources.

HealthCare – PASSHE Group

(Managers, Faculty, Coaches, Nurses, Police)

• PASSHE Enrollment-Change Form (PDF)
• Student Certification Form (PDF)
• Medco Reimbursement Claim_Form (PDF)
• Medco Mail Order Prescription Form (PDF)
• Pennsylvania Blue Shield Claim Form (PDF)
• UCCI Dental Claim Form (PDF)
• Pennsylvania Faculty Benefits – Faculty only
  use this link to obtain claim forms for Faculty Health and Welfare benefits, such as dental, vision, hearing, wellness.

HealthCare – PEBTF Group

(AFSCME, State University Administrators, Physicians)

• PEBTF Employee Enrollment Change Form (PDF)
• PEBTF-7 Student Certification Form (PDF)
• Capital Blue Cross Claim Form (PDF)
• UCCI Dental Claim Form (PDF)
• Medco Reimbursement Claim Form (PDF)
• Medco Mail Order Prescription Form (PDF)

Other

• Salary Reduction Agreement (PDF)
  for Tax Sheltered Annuity Program
• Emergency Contact Information (DOC)