Benefits & Leave Forms
Below you will find commonly used Insurance, Retirement and Flexible Spending Account Forms. In addition, there may be times that you have to obtain forms directly from some benefit vendors. Here are links to certain vendor Web sites:
- NCFlex Benefit Plan Forms
- Teachers’ and State Employees’ Retirement System Forms
- State Health Plan of North Carolina
- Acknowledgement of Offer and Optional Waiver to Decline Coverage
- Affidavit For Domestic Partner
- Lincoln Financial Disability Evidence of Insurability Form
- Lincoln Financial Disability Claim Form
- Lincoln Financial Disability Enrollment Form
- MetLife Life Absolute Assignment Form
- MetLife Life Beneficiary Designation Form
- MetLife Life Conversion & Portability Chart
- MetLife Life Enrollment/Change Form
- MetLife Life Plan Summary and Rates
- MetLife Life Statement of Health Form
- MetLife Will Preparation & Estate Resolution (must be enrolled in UNC MetLife Life plan)
- Reliance Standard AD&D Enrollment Form
- The Standard Enrollment/Change Form
- The Standard Medical Statement Form
- MetLife Dental Domestic Partner Enrollment Form
- 403b Salary Reduction Agreement Form
- ORP-1 Election of the UNC Optional Retirement Program (Please enroll through Connect Carolina Self Service)
- ORP-2 Notice of Change in Election for the UNC ORP
- ORP-3 Acknowledgement of Disposition of Account Contributions for the UNC ORP
- Retirement Election Form
- NC 457b Deferred Compensation Plan Enrollment Form
- NC-401k Enrollment Form
- UNC System 457(b) Salary Deferral Agreement Form
- Attestation of In Loco Parentis Relationship
- COVID-19 Paid Administrative Leave (PAL) Request Form
- Creditable Service Form
- Employee’s Medical Certification, Form WH-380-E (Updated 7/20/20)
- Family & Medical Leave Request Form
- Families First Coronavirus Response Act (FFCRA) Request Form (Updated 8/1/20)
- Family Member’s Medical Certification, Form WH-380-F (Updated 7/20/20)
- Medical Leave Return To Work Form
- Military Caregiver for a Current Servicemember, Form WH-385
- Military Caregiver Leave for a Veteran, Form WH-385-V (Updated 7/20/20)
- Paid Parental Leave Request Form
- Qualifying Exigency, Form WH-384 (Updated 7/20/20)
- Voluntary Shared Leave (VSL) Donation Form
- Voluntary Shared Leave (VSL) Request Form