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Benefits • Staff Forms • Staff Development • Contracts • Evaluation
The following forms are downloadable as PDF files. You must have Adobe Acrobat Reader to open the files. Most computers have this application; if not, you can download Reader at no cost by clicking the icon below:
Forms for District Use
Health Plan Enrollment Forms
BlueCross BlueShield of Vermont enrollment form
Harvard Pilgrim HMO enrollment/change form
Harvard Pilgrim POS enrollment/change form
Walgreen's Prescription Mail-In Service Form
Delta Dental Enrollment/Change Form
Harvard Pilgrim Subscriber Benefits
Below are documents that list subscriber benefits for the various types of Harvard Pilgrim plans:
HP HMO Summary of Benefits & Coverage
HP POS Summary of Benefits & Coverage
HP PPO Summary of Benefits & Coverage
CBI Information and Forms
CBI New Participant Enrollment Booklet
CBI Health Deductible Reimbursement Form
CBI Medical Reimbursement Account Claim Form
CBI Dependent Care Account Claim Form
Other Forms
Lincoln National Life Insurance Company - Life insurance and Long-Term Disability Insurance enrollment form
Payroll Selection Form/Direct Deposit Form - Teachers and Support Staff
26 Pay Days Direct Deposit Form
Salary Reduction Agreement for 403(b) Programs
403(b) Service Providers
Pre-Employment Medical Exam Form
W-4 Form (You can type in this form online before printing)
Vermont W-4 Form
I-9 Employment Eligibility Verification (Read online, then type in your information on Page 7 while online, then print Page 7 and sign.)
Notice of Accidental Injury or Occupational Disease
Employee Address and Name Change Form
Helpful Phone Numbers
Link to Staff Development forms
Updated 5/13/13
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