Montclair, NJ 07043

Patricia Kelly, Director of Employee Services Payroll and Benefits
Helen Caruso, Benefits Specialist
Diane Gasparatos, Program Assistant
Division of Human Resources                                                                                                 Employee Benefits Forms
College Hall 314
Fax: 973-655-4351
hr@mail.montclair.edu

Listed below are many of the forms frequently used by the Office of Employee Benefits in the Division of Human Resources. All documents are in PDF format. Some documents are also available in MS Word* format. Download them as needed. Please contact this department at extension 4395 for a copy of a form not available on this page. If you do not have Acrobat Reader installed on your computer you can download a free copy at: Adobe's Acrobat site. 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 07/06)

Links to Other HR Forms Adjunct Faculty, Visiting Specialists, Summer Session Faculty Classified Staffing Equal Opportunity/ Affirmative Action Frequently Used Forms Managerial Staff Payroll Student Employment Unclassified Staffing Useful Links MSU Office of Career Development NJ Dept. of Personnel NJ State Job Opportunities

GUIDELINES, PROCEDURES AND POLICIES State Health Benefits Coverage for Part-Time Faculty Members and Staff NJ State Domestic Partner Act FORMS FORM NAME FORMAT PURPOSE OF FORM ABP Salary Reduction Agreement PDF To authorize a percentage reduction in an employee's salary to make additional voluntary contributions on a tax-deferred basis beyond that required by the Alternative Benefits Program ACTS Salary Reduction Agreement PDF 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. Affidavit of Dependency PDF To document the eligibility of employee's dependent children to receive health benefits. Designation of Beneficiary PDF To nominate a beneficiary for receipt of relevant benefits upon death of the member. Drug Plan Mail Order Form PDF To order/refill three months' supply of prescriptions. Health Benefits Program Application Form (Full-Time) PDF To enroll in health benefits or update information Health Benefits Program Application Form (Part-Time) PDF To enroll in health benefits or update information if you're a part-time faculty or staff member. Leaves of Absence Forms and Procedures   Please visit the Benefits web page. NJ Direct Claim Form (New Jersey State Health Benefits) PDF To file a NJ Direct Claim for out of network health care benefits NJ State Dental Expense Plan Claim Form PDF To file an Aetna claim for dental benefits NJ State Dental Plans Application (Full-Time) PDF To enroll in dental benefits or update information Purchasing Service Credit PDF To purchase additional service credit if eligible to do so Request for Retirement Estimate PDF To obtain a retirement fund estimate for members of PERS and TPAF retirment funds Request for Retirement Estimate PDF To obtain a retirement fund estimate for members of PFRS retirement funds SHBP Waiver/Reinstatement Form PDF To waive or reinstate enrollment in SHBP PERS, TPAF or PFRS Loan Application PDF To borrow funds from your retirement account. Traditional Plan Claims Form (NJ State Health Benefits) PDF To file a claim for Traditional Plan Health Care benefits Spring 2008 Special Open Enrollment Form PDF To enroll in new SHBP plans for plan year 2008