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Forms

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Listed below are all of the forms and documents used by Human Resources.

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Benefits

• Agreement for Salary Reduction Under Section 403(b) [pdf]
  Voluntary Tax Sheltered Annuity 403(b) Deduction and Change Form.
• Benefits Enrollment and Change Form [Web]
  PEBP: BECF Please contact the Benefits Office to obtain a form at (775) 784-6163.
• Classified Grants-in-Aid [Web]
  VPAF 103 For tuition payment for classified employees. For more information on filling out the form, call (775) 784-6082.
• Deduction Stop Form [pdf]
  Deduction cancellation for supplemental benefit forms
• Dental Claim Form [pdf]
  For dental claim reimbursement
• Designation of Beneficiary for Unpaid Compensation Form [pdf]
  This form allows employees to designate one or more beneficiaries to receive the amount of any unpaid compensation in the event of the employee's death.
• Faculty Grants-in-Aid [Web]
  UNR For payment of a specified portion of the registration fee for faculty and eligible dependents. For more information on filling out the form, call (775) 784-6082.
• FICA Enrollment Form-Continuing Employee [doc]
  FICA Alternative Form for continuing Classified Temporary Casual and Faculty Employees.
  Last Updated: January 2009
• FICA Enrollment Form-Newly Hired Employees [doc]
  Used by departments for hiring new Classified Temporary Casual and Faculty Employees.
  Last Updated: January 2009
• Hartford Deferred Compensation 457 Change Form [pdf]
  Voluntary Deferred Compensation 457 Change Form for Hartford Insurance Company
• ING Deferred Compensation 457 Change Form [doc]
  Voluntary Deferred Compensation 457 Change Form for ING Life Insurance and Annuity Company.
• Life Insurance Beneficiary Form [Web]
  The Standard Insurance Company provides life insurance for all employees covered by PEBP Benefits. Complete this form to update your beneficiary for this benefit.
• Medical Claim Form [pdf]
  For state self-funded medical and vision plan claims reimbursement.
• Medical Resident / Postdoctoral Fellow Company Allocation Form [pdf]
  Retirement Plan Enrollment and Change Form.
• Metlaw Enrollment Form [pdf]
  Enrollment form for the Metlaw Legal Plan by Hyatt.
  Last Updated: May 2012
• PERS Change of Member Contribution Plan [pdf]
  For a PERS member who is changing from the employee/employer contribution plan to the employer-pay contribution plan.
• PERS Member Enrollment Form [pdf]
  This form should be completed for all new hires that are eligible for enrollment under NRS 286.293. This form is also used to enroll persons who have returned from leave without pay or from ineligible status, or for a retired employee electing to re-enroll under authority of AB 555.
  Last Updated: November 2006
• PERS Survivor Beneficiary Designation [pdf]
  This form should be completed for the designation of a beneficiary once the member has established eligibility for survivor benefits.
  Last Updated: May 2012
• Phase-In Retirement Application (RPA Plan) [pdf]
  Faculty Retirement Plan (not PERS). PERS members should contact HR for a Phase-In Retirement Application.
• RPA Allocation Form [pdf]
  Faculty Retirement Plan Enrollment and Change Form.
• Section 125 Direct Deposit Form - ASI [pdf]
  Speed up the receipt of your Section 125 reimbursement with direct deposit; have it paid directly into your bank account.
• Section 125 Request for Additional Debit Card - ASI [pdf]
  Get a debit card for your Spouse or Dependents with this form.
• SSA-1945 Windfall Elimination Provision [doc]
  Explanation and Statement concerning Employment in a job that is not covered by Social Security. Used for Classified and Faculty Employees.
  Last Updated: December 2004

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