Forms - Office of Human Resources, Oregon State University

Benefit Forms

Enrollment Forms
Health Coverage (Medical, Dental, & Vision)

PEBB Enrollment Form

(.pdf file)

PEBB Affidavit of Domestic Partnership

(.pdf file)
Life and Disability

PEBB Life and Disability

(.pdf file)

Standard Medical History Statement

(.pdf file)

Standard Medical History Statement Online

Flexible Spending Account

Dependent Care

(.pdf file)

Health Care

(.pdf file)

Long Term Care

Update Forms
Health Coverage (Medical, Dental & Vision)

PEBB Update Form

(.pdf file)

PEBB Affidavit of Dependency

(.pdf file)

PEBB Termination of Domestic Partnership

(.pdf file)
Life and Disability

Life and Disability

(.pdf file)
Flexible Spending Account

Dependent and Health Care

(.pdf file)
Beneficiary Designation

PEBB (Life and Disability)

(.pdf file)

PERS Tier One/Tier Two (retirement)

(.pdf file)

PERS IAP (retirement)

(.pdf file)

Reimbursement Forms

Regence BCBSO Form (claims, Rx, Rx mail order, etc.)

(.pdf file)

Dependent Care and Healthcare Flexible Spending Account Claim Form

(.pdf file)

VSP Reimbursement Form

(.pdf file)

Samaritan Select - Mail Order Pharmacy

Staff Free Privileges

Enrollment Form (.pdf file)

Tax Deferred Investment and Savings Plan

Tax Deferred Investment (403b) Salary Reduction Agreement

(.pdf file)

Oregon Savings Growth Plan (457) Forms

Workers' Compensation Forms
Important Information for Employees with Occupational Injuries (.pdf file)

SAIF Claim Form 801

(.pdf file)
Instructions for Completing the 801 (.pdf file)
OSU Report of Accident (.pdf file)
Employee Status Report (.doc file)
Continued Benefits for Injured Workers Notice (.pdf file)

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