Print Forms
For more information contact:
- Suzie Torre-Cross, CEBS
- (503) 370.6210 ext. 4043
- storre@willamette.edu.
You can view and print any necessary form related to your benefits.
Checklist for New Employees
- New Employee Benefits Checklist
- Regence Blue Cross/Blue Shield: Short-term, Interim Medical Insurance
Medical/Dental and Flexible Spending Enrollment/Change Forms
Claim Submission Forms
- Medical/Dental/Vision
- Prescription
- PPS Mail Order prescription refill
- Health Care or Dependent Care Expenses (FSA)
- Mass Transit (eFlex)
Basic Life, Optional Life, AD&D, and Long-Term Disability (LTD)
- Life Insurance Beneficiary Designation Form
- Optional Life Insurance Enrollment Form
- Evidence of Insurability (for Optional Life Insurance)
- Verification of Prior Coverage (LTD)
Tuition Remission Benefit Forms
- Dependent Application Form
- Spouse/Domestic Partner Application Form
- Faculty and Staff Application Form
- Facutly and Staff Graduate Tuition Benefit Taxability FAQ
Spouse/Domestic Partner Affidavit
On-the-job Injury
- Incident Only Report Form
- First Report of Injury/Illness Report (Form 801)
- Physician Claim form for Worker's Compensation
- Work Release Form (to be completed by physician)
Leave of Absence Including Family/Medical Leaves
- Oregon Family Leave Law (OFLA) Information
- Family Medical Leave Law (FMLA) Information
- Leave of Absence Application Form
- Medical Certification Form - Required If:
1. You are taking leave for your own serious health condition
2. You are taking leave to care for your family member
3. You are taking time off to care for a servicemember
Shared Leave Program
- Shared Leave Policy
- Shared Leave Request Form
- Shared Leave Donation Form