Human Resources

Family & Medical Leave Information

FMLA Request Form
Please fill out and turn in to your building principal.
FMLA Certification of Physician or Practitioner
This form is needed if you are requesting leave for yourself or a family member for medical reasons.
Family or Medical Leave Intermittent Absence Report
This form is needed if you are have been approved for and using family medical intermittent leave for each medical appointment.
Work Status Report Form
This form should be completed by your physician if you will be on a reduced work schedule.
FMLA Posting

Health Care Information

Health Plan Notices of Privacy Practices
Humana 2014 Health Plan Comparisons
Humana Summary Plan Description 2014
Welcome to your employer-sponsored health care plan administered by Humana Insurance Company. Your employer has provided you with the three Summary Plan Descriptions listed below, which outline your benefits, as well as your rights and responsibilities under this Plan.
Humana PPO 1,000 Summary of Benefits (Option 1)
Humana PPO 1,000 Plan Description (Option 1)
Humana PPO 1,250 Summary of Benefits (Option 2)
Humana PPO 1,250 Plan Description (Option 2)
Humana HDHP Summary of Benefits
Humana HDHP Option Plan Description
Affordable Care Act (ACA) Glossary of Medical Terms
FAQ Health Risk Assessment Program
This document contains a list of the most frequently asked questions regarding our Health Risk Assessment Program.
Hines Pre-Certification Letter
Hines Outpatient Procedure List
For pre-certification please call Hines at 866-874-8721.
BENCO: Pending or Rejected Claims Memo
NAVITUS Health Solutions
NAVITUS Navi-gate
EBC Flex Account Information
Links you to the EBC website for forms or information on employee flex accounts.

Dental Information

Delta Dental Summary Plan Description 2014
Welcome to your employer-sponsored dental care plan administered by Delta Insurance Company. Your employer has provided you with the two Summary Plan Descriptions listed below, which outline your benefits, as well as your rights and responsibilities under this Plan.
Delta 2014 Dental Plan Comparisons

Retirement Information

Wisconsin Retirement System
Links you to the Department of Employee Trust Funds, your source for the Wisconsin Retirement System benefits.
Notice of 403b Plan Eligibility
403b Tax Shelter Information
403b Instructions

Payroll Forms

Direct Deposit Agreement
Submit this completed form along with a voided check to the Payroll Office located in the Administration Building.
W4 - 2014

The School District of Cudahy does not discriminate on the basis of sex, race, religion, national origin, ancestry, creed, pregnancy, marital or parental status, sexual orientation or physical, mental, emotional, or learning disability.

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