
Forms
General
Employee Retirement/Resignation Form
Name/Address/Phone Number Change Form
MESPA Tuition Reimbursement Form
Workers' Compensation
Employee Injury Report Form (to be completed by Employee)
Employer Basic Report of Injury Form (to be completed by Building Administrator)
Instructions for Completing the Employer Basic Report of Injury Form
Appendix B
Leave Request Forms
Used for an absence of five (5) or more days. Must be turned in to Human Resources for approval.
ESOS, MESPA, SASA, SEA, UNAFF
Leave Extension Request Forms
Used to extend a current leave of absence. Must be turned in to Human Resources for approval.
ESOS, MESPA, SASA, SEA, UNAFF
ESOS
Secretarial Overtime & Extra Help Request Form
Insurance
SASA/UNAFF/UNAFT Mutual of Omaha Life Insurance Beneficiary Designation Form
MESSA Member Change Form
Used to add/remove dependents/optional benefits or name/address changes.
MESSA Member Application
Used to re-instate recalled employees and to switch from Pak A (full coverage) to Pak B (no medical).
MESSA CIGNA Life Insurance Beneficiary Designation Form
MESSA CIGNA Life Insurance Beneficiary Address Form
MESSA COBRA Application
Used to elect employee paid group health coverage.