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Seton Hall University

Benefits Forms  

Aetna Life Insurance Company Designation of Beneficiary
Use this form to designate a beneficiary for the Aetna Life Insurance policy.

Aetna Life Insurance Company Enrollment Form
Use this form to enroll for an Aetna Insurance Policy or submit a change request to an existing policy.

Certification of Health Care Provider for FMLA.
Medical Certification for FMLA

Cigna Behavior Health Customer Claim Form
Download the Cigna Behavior Health Customer Claim Form.

Cigna Dental Claim Form
Download the Cigna Dental Claim Form.

Cigna Health Care Enrollment Form
Enroll in a Cigna medical and/or dental plans.

Cigna LTD Buy-Up Form for Evidence of Insurability
Cigna LTD Buy-Up Form for Evidence of Insurability for Disability Insurance

Cigna Medical Claim Appeal Request
Download the Cigna Medical Claim Appeal Request Form.

Cigna Medical Claim Form
Download the Cigna Medical Claim Form.

Cigna Transition of Care Form
Download the Cigna Transition of Care Form

Cigna Vision POS Claim Form
Cigna Vision POS Claim Form Document

Commuter Benefit Plan (CBP) Reimbursement Claim Form
Download the Commuter Benefit Plan (CBP) Reimbursement Claim Form in PDF format.

Commuter Benefit Plan Change Form
Download the Commuter Benefit Plan Change Form in PDF format.

Commuter Benefit Plan Enrollment Form
Download the Commuter Benefit Plan Enrollment Form in PDF format.

Dependent Eligibility Affidavit for Tuition Remission
Download Dependent Eligibility Affidavit for Tuition Remission in PDF format.

Dependent Eligibility Verification - Medical and Dental Coverage Affidavit
Download the Dependent Eligibility Verification - Medical and Dental Coverage Affidavit in PDF format.

Employment Verification Form to apply for early entry into the Matching Retirement Plan
Form to apply for early entry into the Seton Hall University Matching Retirement Plan.

Express Scripts - Prescription Drug Reimbursement / Coordination of Benefits Claim Form
Use this form to process Prescription Drug Reimbursement and/or Coordination of Benefits Claim.

Express Scripts - MEDCO Mail Order Form
Download the Express Scripts - MEDCO Mail Order Form.

Family Medical Leave Employee Request Form
Family Medical Leave Employee Request Form

TIAA-CREF Salary Reduction Agreement
Initiate, change or suspend payroll deductions for the Supplemental Retirement Plan.

Tuition Remission Application
Complete for each semester you enroll

Tuition Remission Application - Job Related Graduate (Employee Only)
Job Related Graduate Tuition Remission Application Employees Only Form.

Tuition Remission Lunch Hour Waiver
Waive lunch hour in order to attend class(es)

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