Benefits Forms
Department of Human Resources
Benefit Concepts – Flexible Spending Account Enrollment Form
FSA Enrollment Form per Calendar Year to enroll in the Health Care Reimbursement and/or Dependent Care Reimbursement
 
Benefit Concepts – FSA Dependent Care Reimbursement Form
FSA Dependent Care Reimbursement Form and Instructions
 
Benefit Concepts – FSA Health Care Reimbursement Claim Form
FSA Health Care Reimbursement Claim Form and Instructions
 
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 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 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
 
Flexible Spending Account – Carryover Information
Information on Flexible Spending Account Carryover Information
 
Hartford - Beneficiary Designation Form
Designate beneficiary to receive proceeds from Group Life insurance and Accidental Death & Dismemberment.
 
Hartford - Faculty and Admin Supplemental Life and AD&D Enrollment Form
Download the Hartford - Faculty and Admin Supplemental Life and AD&D Enrollment Form.
 
Hartford - Union and Non-Union Staff Supplemental Life and AD&D Enrollment Form
Download the Hartford - Union and Non-Union Staff Supplemental Life and AD&D Enrollment Form.
 
LTD Buy-Up Enrollment Form - Faculty and Admin
Long Term Disability Buy-Up Enrollment Form for Faculty and Administrators.
 
LTD Buy-Up Enrollment Form - Union and Non-Union Staff
Long Term Disability Buy-Up Enrollment Form for Union and Non-Union Staff.
 
TIAA-CREF Salary Reduction Agreement
Initiate, change or suspend payroll deductions for the Supplemental Retirement Plan.
 
Tuition Exchange Scholarship Application
Tuition Exchange Scholarship Application.
 
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)
Contact Us

Department of Human Resources
(973) 761-9177
Fax (973) 761-9007
humanres@shu.edu
Martin House

Mailing AddressDepartment of Human Resources
Seton Hall University
Martin House
366 South Orange Avenue
South Orange, NJ 07079

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