Do you need to... 

♦ Change your name, HR Address
* or SSN?

Change Form 

♦ Update your W4?

W4 Form 

♦ Start, stop, or change your Direct Deposit?

Direct Deposit Form
Where do I send my form?

• Fax to:
(907) 474-5859;

• Mail to: 
PO Box 757860, 
Fairbanks, AK, 99775;
• Bring to: 
3295 College Rd,
Room 108

**You may now change your HR Address online
For instruction on this new process, please watch the video below:

Benefits Forms

Benefits Forms

Commonly Requested Benefits Forms:
Annual Leave Cash-In Request for Non-Union Employees
Beneficiary Designation
Financially Interdependent Partner (FIP) Statement
Premera Blue Cross Blue Shield Claim Form
TDA Salary Reduction Agreement
Tuition Waiver Request
UA Choice Health Plan Enrollment Form
UA Choice Supplemental Benefit Election Form

Turning in my forms - what else do I need?
When adding a dependent or FIP to your insurance, we need to receive backups for anyone you wish to put on your plan. This requirement includes life events, open enrollment and first time benefits selection.

Please see our list below for what we need from you:

     • To add a spouse: marriage certificate*

     • To add a child: birth certificates*^

     • To add a FIP: UA Statement of Financial Interdependence and all supporting documentation 

*These documents may simply be brought in for verification; we do not need to retain a copy. 

^If you have not yet received the birth certificate for your child, you may bring a letter from your hospital instead. Premera will send a card for your child, however you must complete enrollment forms in order to continue coverage.

Please provide a copy of documentation, such as 
marriage certificate, birth certificate, legal adoption papers, legal guardianship papers from a court of law.

Health Forms & FSA

Health Forms

Commonly Requested Health Forms:
Financially Interdependent Partner (FIP) Statement
FML Request Form
FSA Enrollment/Claim Forms
HSA Enrollment Forms
Premera Blue Cross Blue Shield Claim Form

UA Choice Health Plan Enrollment Form
UA Choice HSA Enrollment/Change Form
UA Choice Opt-Out Form
UA Choice Supplemental Benefit Election Form
UA Wellness Program Rebate

Payroll Forms

Payroll Forms

Commonly Requested Payroll Forms:
Annual Leave Cash-In Request for Non-Union Employees
Direct Deposit Request Form
Employee Selected Deduction Form
Timesheet Exempt
Timesheet Nonexempt
UA College Savings Plan Payroll Deduction Request Form
W-4 Form

Retirement Forms

Retirement Forms

Commonly Requested Retirement Forms:
Retirement Plan Election Form (TRS/PERS/ORP)

TDA Salary Reduction Agreement
TIAA-CREF ORP Account Enrollment Form
TIAA-CREF Transfer/Rollover/Exchange Authorization Form
TIAA-CREF UA Pension Plan Enrollment Form
Fidelity Beneficiary Designation Form
Fidelity Enrollment and Beneficiary Designation Form
Fidelity Address/Name Change
Fidelity Transfer/Rollover Form

Retirement Plans and Information

For all other UA Forms, please see the UA Statewide forms page at the link below:

Statewide Forms Page

Understanding the term "Life Event"

Certain benefit options may be changed within 30 days of a major life event. These include changes in you or your spouse's jobs, birth or adoption*, death, marriage or divorce.

For more information on major life events, please review our checklist below:

Major Life Event Checklist

Exception: for birth or adoption of a child you have 60 days.

Note for births: Temporary card is issued by Premera, however you must submit an enrollment form to add your newborn to your plan.

Employment Forms

Employment Forms

Commonly Requested Employment Forms:
Change Form
(Disclosure of) Employment of Immediate Family Member Form
Employment or Service Outside UA Disclosure Form
I-9 Form
(Previous) Injury/Illness Form
Employees/Rehired Retirees
Student Employee Waiver Form
Student Status Verification
UA Computer Account Request Form
UA System Administrative Access Request Form
W-4 Form

Leave Forms

Leave Forms

Leave Forms at UA:
Annual Leave Cash-In Request for Non-Union Employees
FML Leave w/o Pay (FMLWOP), Sick Leave (LWOP) Form
FML Request Form
FMLA Certification Forms (DOL External Site)
Leave Share Donation Form
Leave Share Transfer Request Form

Union Forms

Union Forms

Union Forms at UA:
FFA Membership Dues Deduction Form
FFA Voluntary PAC Deduction Form
Local 6070 Membership Dues or Fees Deduction
UAFT Service Fee Deduction Form
UAFT Service Fee Revocation Form
UAFT Union Sick Leave Bank - Application for Withdrawal
UAFT Upper Division Release
United Academics Adjuncts AAUP/AFT Dues Deduction
United Academics Dues or Agency Fee Deduction
United Academics Dues or Agency Fee Revocation

For the A - Z Forms Index, which gives a small explanation of each form, please use this link:

A to Z Index of Forms

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