Forms For Employees

Employment Forms
Benefits Forms:

Payroll

 

EMPLOYMENT

Address and Emergency Contact Information - to update: Click here to go to "MyPace Portal"

Once you login to "MyPace Portal" click "Personal Information" and make necessary changes. An address change does not make an automatic tax change. Please fill out the appropriate tax form (see below under Payroll) and submit to the Payroll office.

Application For Student Employment (Fill in Pdf)

 Form for students to apply for an on-campus job at Pace

Disability Accommodations: Request and Authorization to Release Certain Health Information  (Pdf)

Complete when requesting the University to obtain information from your Licensed  professional certifying your disability in connection with your reasonable accommodation.

Disability Accommodations: Notice and Understanding Concerning Request for a Reasonable Accommodation  (Pdf)

Complete to fully evaluate and consider an employee's request for reasonable accommodation
Drug & Alcohol/Sexual Harassment Acknowledgement Form (Word Doc)

Complete to acknowledge you received the the Policy on Alcohol and a Drug Free Environment and the Policy on Sexual Harassment

Flexible Work Arrangement Proposal Request

(Fill in PDF)

 Employee to Complete when requesting a Flexible Work Arrangement
Flexible Work Arrangement Agreement

(Fill in PDF)

 Supervisor to complete when employee is requesting a Flexible Work Schedule
Personal Data Form  (Fill in Pdf) Complete to notify Human Resources of a change in name, address, telephone, and other personal information.

Information Release And Waiver Agreement (Fill in Pdf)

 Complete when requesting the University to release information to a third party about your employment at Pace.

BENEFITS

General Forms

FMLA Medical Certification (Pdf)

This must be completed by treating physician when requesting unpaid time for a serious health condition that makes you unable to perform the functions of your job or a condition that affects a spouse, child or parent for whom you need to provide care.

Change in Family Status (Pdf)

Completed to authorize payroll deductions/adjustments when there is a change in benefit coverage level due to birth, adoption, marital status, dependent status or spouse/partner employment status.

Universal Medical Enrollment Form  (Pdf)

This form is to be completed when enrolling in one of the medical plans at Pace University or making a change to medical coverage as a result in a change of family status.

CIGNA Dental Enrollment Form (Pdf)

This form is to be completed when enrolling in one of the dental plans at Pace University or making a change to dental coverage as a result in a change of family status.

Statement Of Domestic Partnership (Pdf)

Please submit this form, which has been fully-completed and notarized, along with supporting documentation (showing at least 2 years of common residency and 2 years of financial interdependence), to register a Domestic Partner with the University Benefits office.
New York's 529 College Savings Enrollment Kit (Pdf) Use the application form included in this kit to open an account in New York's 529 College Savings Program Direct Plan.  
New York's 529 College Savings Payroll Deduction Authorization Form (Pdf) Use this form to have money automatically deducted from your paycheck and deposited into an account in New York's 529 College Savings Program Direct Plan, or if you want to change your existing deduction (If you're opening a new account you'll also need to submit an Enrollment Application - See New York's 529 College Savings Enrollment Kit Form.  
Preventative Care Incentive Program Payment Form 2012-2013 Employee's who are enrolled in the University's medical plan may use this form to receive a cash payment for having certain qualified preventative care examinations as outlined in the Preventative Care Program. Return the completed form by email, signed by a healthcare provider, along with the corresponding Explanation of Benefits (EOBs) to the University Benefits office at PCare@pace.edu by August 31, 2013.  
     

Medical/Dental
Out of Network Claim Form - CIGNA (Pdf) This form is to be completed when processing an out of network claim through CIGNA HealthCare.  Out of network claims must be filed within 180 days from date of service.
CIGNA Mail Order Form (Pdf) This form is to be completed in order to participate in the mail order Prescription drug program through CIGNA HealthCare.
CIGNA Prescription Drug Claim Form (Pdf) This form is to be completed in order to process a claim through CIGNA, the pharmacy benefit administrator.  Please forward the completed form and prescription receipt(s) directly to CIGNA at the address listed on the form.
CIGNA Vision Claim Form (Pdf)

This form is to be completed to obtain the applicable reimbursement for an out-of-network vision exam or vision hardware through the CIGNA Vision program.
Dependent Tax Affidavit (Pdf)

Please submit this (notarized) Affidavit to the University Benefits office (via fax to 914-989-8506 or scan/email to benefits@pace.edu) to affirm that your registered domestic partner/same-sex spouse and the children of your registered domestic partner/same-sex spouse (who are enrolled in the medical and/or dental plans offered by Pace University) qualify as your dependents under Section 152 of the Internal Revenue Code.
Student Verification Form (Pdf)

This form is to be completed and submitted to CIGNA to verify a student's disability status or full time status in a college or university.
CIGNA Provider Referral Form (Word) This form is to be completed and submitted to CIGNA to refer a provider currently not participating in the CIGNA Open Access Plus Plan

CIGNA Dental PPO Claim Form (Pdf)

Dental plan claim form for submission to dental carrier as of July 1, 2010.

Life Insurance

Beneficiary Designation/Change Form (Pdf)

 

This form must be faxed to the University Benefits office, at 914-989-8506, to change beneficiary designation (which can be completed at any time during the year).

Reimbursement Accounts
PayFlex FSA Claim Form (Pdf) Complete this form to be reimbursed for eligible health care and/or dependent child care expenses for the new FSA plan year from 7/1/12– 6/30/13. Please note – the grace period, for the health care FSA only, is from July 1, 2013 through September 15, 2013. All health care FSA expenses must be submitted to PayFlex by September 30, 2013.

2013 Commuter Enrollment/Change Form        (Pdf)

Complete this form to enroll and/or make changes to the transit or parking reimbursement accounts.
*Fax to 914-989-8506
BRI Commuter Claim Form (Pdf) Complete this form to be reimbursed for mass transit expenses or parking expenses through the commuter reimbursement account. For further information, please visit the BRI website at www.BenefitResource.com.

Retirement

 

  

2013 Defined Contribution Retirement Plan (403b) Salary Agreement Form (Pdf)

Please complete this form to enroll in the plan or to change your contribution for 2013. (Instructions, for online web enrollment with TIAA-CREF, are included at the bottom of the form.) The IRS maximum contribution for 2013 is $17,500 (plus an additional $5,500 for those aged 50+). Please fax the completed form to the University Benefits office at (914) 989-8506.

Tuition
On Campus Tuition Remission Application Undergraduate/Center for Business & Technology Complete this form when enrolling yourself, your spouse, and/or your eligible dependent child(ren) in undergraduate courses at Pace University through the On-Campus Tuition Remission program and  when enrolling yourself in eligible courses through the Pace Center for Business and Technology. Please fax the completed form to the University Benefits office, at (914) 989-8506, for final approval. The University Benefits office will return the signed form to the employee for submission to OSA@pace.edu or the Pace Center for Business and Technology.
On-Campus Tuition Remission Application Graduate Level (Pdf) Complete this form when enrolling yourself, your spouse, and/or your eligible dependent child(ren) in graduate courses at Pace University through the On-Campus Tuition Remission program. Note: The form must be faxed to the Payroll Office, at (914) 923-2681, prior to submission to the University Benefits office for final approval. The Payroll Office will forward the form to the University Benefits office.The University Benefits office will return the signed form to the employee for submission to OSA@pace.edu.
Application to Participate in the Tuition Exchange, Inc. Program (Pdf)

Please return the completed application to the University Benefits office by Wednesday, October 24, 2012. The form can be faxed (to 914-989-8506) or scanned/e-mailed to benefits@pace.edu. Receipt will be verified via confirmation e-mail within 24 business hours.
Application to Participate in the Council of Independent Colleges Program (Pdf) Please return the completed application to the University Benefits office by Wednesday, October 24, 2012. The form can be faxed (to 914-989-8506) or scanned/e-mailed to benefits@pace.edu. Receipt will be verified via confirmation e-mail within 24 business hours.
Application for Recertification of Tuition Exchange Scholarship in 2013 – 2014(Pdf) Please return the completed application to the University Benefits office by Wednesday, October 24, 2012. The form can be faxed (to 914-989-8506) or scanned/e-mailed to benefits@pace.edu. Receipt will be verified via confirmation e-mail within 24 business hours.

Off-Campus Dependent Tuition Assistance Application (Pdf)

Complete in order to process a $300 reimbursement for children up to age 24 who attend another university at the undergraduate level on a full time basis.  Transcript for completed semester must accompany form.

Off Campus Tuition Remission Application (Pdf)

This form is for full-time faculty and staff who are enrolled in a job-related graduate program not offered at Pace University. Please fax the form, paid receipt, and grade report to the University Benefits office at (914) 989-8506. Reimbursement for the fall semester will be made in January and reimbursement for the spring semester will be made in June. Please review the policy, on the HR web page, prior to submission for reimbursement.
Payroll
Form W4 (Fill in PDF) Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.