Online Benefits Orientation: Checklist

When you have finished the online orientation and made your benefit elections, please complete this checklist to acknowledge you have reviewed the benefits information and completed necessary forms. Print, sign, and bring this checklist along with all other forms to the Employee Benefits Office, Cleveland Hall 410, within 30 business days of your appointment. Contact the Employee Benefits Office if you have any questions at 878-4821.

Name:
Title:
Telephone:
Campus Appointment Date:

Health Insurance:
	I do not wish to enroll in health insurance. Proceed to Dental and Vision Care. Empire Plan Blue Cross Blue Shield of WNY (Community Blue) (HMO) Independent Health (HMO) Health Insurance Enrollment Form (PS-404) (required if enrolling)
Coverage Type:
	individual family
If electing family coverage, attach a copy of the following documentation:
	marriage certificate if married over one year, attach current proof of financial interdependence birth certificate(s) for all dependents Social Security card(s) for all dependents

Dental and Vision Care:
	Completed UUP Enrollment Card

Retirement Plans:
	I wish to join the Optional Retirement Program (ORP).
	I wish to join the NYS Teachers' Retirement System (TRS).
	I wish to join the NYS Employee's Retirement System (ERS).
		Retirement Election Form Plan Application (ERS, TRS, or TIAA-CREF)
	I am presently a member of NYS Teacher's (TRS) or the NYS Employee's Retirement System (ERS).
	Membership Date: Number: Tier:
	(enter format: mm/dd/yyyy)

	I do not wish to join a retirement plan at this time (optional only for those with part-time appointments).

Tax Deferred Annuities and College Savings Program:
	I have reviewed the information

Flexible Spending Accounts (Dependent Care Advantage and Health Care Spending accounts):
	I have reviewed the information

Vacation and Sick Leave:
	I have reviewed the information

Insurances:
	Disability Coverage Waiver request completed (Statement of Eligibility)
	Long-Term Care Insurance (optional) Completed NYPERL Employee Notice and Fact Sheet
	Mass Marketed Insurance (optional)

Education:
	I have reviewed the information

Payroll Forms and Emergency Contact Information:
	NYS IT-2104 (state)
	W-4 (federal)
	Payroll Calendar
	Direct Deposit (optional)
	Emergency Contact Information Form
	Credit Union (optional)
	U.S. Savings Bonds (optional)

Campus Information and Policies:
	Campus Map and Directions
	Employee Orientation and Handbook
	Workplace Violence Prevention Training
	Safety Awareness
	Holidays
	Employee Assistance Program
	Child Care Center
	Policy on Alcohol and Drug Use in the Workplace
	General Policy Against Discrimination and Harassment

Copyright © 2001-2013 Human Resource Management, Buffalo State, 1300 Elmwood Avenue, Cleveland Hall 403, Buffalo, NY 14222
Telephone: (716) 878-4822, FAX: (716) 878-3068
Questions, comments, and concerns may be sent to: .