Benefits

Listed below are many of the forms frequently used by the Office of Employee Benefits in the Division of Human Resources.  If you have any problems using this page or downloading forms, please email hr@mail.montclair.edu


* Please note that any changes made to these Word templates without the consent of the Division of Human Resources will result in the form being returned to the appropriate Division or Department for resubmission on the HR version. (Last updated 2/14)

Guidelines, Procedures and Policies

State Health Benefits

Form Name Purpose
Health Benefits Program Application Form (Full-Time) (Full-Time To enroll in health benefits or update information.
Health Benefits Program Application Form (Part-Time) (Part-Time) To enroll in health benefits or update information.
High Deductible Health Plans for (Full-Time) (Full-Time) To enroll in health benefits for full-time staff.
High Deductible Health Plans for (Part-Time) (Part-Time) To enroll in health benefits for full-time staff.
Health Benefits Program Application Form (Retiree) To enroll in health benefits or update information if you are a retiree
Health Benefits Program Application Form (Retiree Medicare) To enroll in health benefits or update information if you are a retiree
Dependent eligibility documents Required documents for SHBP/SEHBP dependent eligibilty and enrollment
Application for Chapter 375 Coverage - Dependents to age 31  To apply for coverage of a child up to age 31
Dental Plan Application (Full-Time) (Full-Time) To enroll in dental benefits or update information
Waiver/Reinstatement Form To waive or reinstate enrollment in SHBP
Affidavit of Dependency Form To determine eligibility of dependent child/children

Claim Forms

Form Name Purpose
NJ Direct Claim Form To file a NJ Direct claim for out of network health care benefits
Express Scripts/Medco Claim Form To file a claim for reimbursement for prescriptions 
Mail Order Express Scripts/Medco Claim Form To file a claim for reimbursement for mail order prescriptions
Dental Expense Plan Claim Form  To file an Aetna claim for dental benefits

TaxSave/Flexible Spending Account

Form Name Purpose
WageWorks Enrollment Form‌ To enroll in tax-free medical or dependent care program

Public Employee's Retirement System (PERS)

Form Name Purpose

The Forms below must be completed On-line through MBOS

 

‌Disability Retirement Application 

 To apply for disability retirement under PERS

Request for Retirement Estimate

 To obtain a retirement fund estimate for members of PERS and TPAF  retirment funds

PERS  Enrollment Application

 To apply for PERS retirement
Adjunct/Part-timeInstructors ABP Election of Retirement Coverage Form To request a transfer of pension contributions to ABP or remain in PERS
ACTS Salary Reduction Agreement To authorize a percentage reduction in an employee's salary to make additional voluntary contributions on a tax-deferred basis beyond those required by the mandatory membership in any state-administered retirement system.

Alternate Benefit Program

Form Name Purpose
ABP Common Questions and answers Alternate Benefit Program frequently asked questions
ABP Member Handbook NJ State Alternate Benefit Program Member Handbook
ABP Enrollment Application Active employee application for ABP enrollment
ABP Carrier Election Form To file choice of carrier under ABP
ABP Retirement Application To apply for retirement under ABP
ABP and DCRP Beneficiary Designation To nominate a beneficiary for receipt of relevant benefits upon death of the member
ABP Long Term Disability Application To apply for long term disability under ABP
Choosing between PERS and ABP To assist newly eligible employees currently in PERS, TPAF, or PFRS in determining whether the PERS or the ABP system is better for them.
Election of Coverage Form for Adjuncts and Part Time Instructors Within 30 days of commencing employment, Adjuncts and Part-Time Instructors with existing PERS membership must complete an Election of Coverage Form.
Salary Reduction Agreement - Supplemental Savings Plan To authorize salary deductions for the supplemental 403b plan

Deferred Compensation Plan for enrollment or investment option information:

Leaves of Absence

Form Name Purpose

Family Medical Leave Act Procedures

Federal and State Family medical leave information 
Personal Leave Information & application for personal leave
Flex-Time Request Form Information and Request for Flex-time Work Schedule
Extended Sick Leave Information & application for extended leave
Family Leave Insurance Form Application for Family Leave Insurance
Temporary Disability Form Application for Temporary Disability

Donated Leave Program for Classified Employees and Unclassified Professional Staff and Librarians

Form Name Purpose
Donated Leave Donated Leave Program