Forms

Beneficiary Designation:

A beneficiary designation is necessary for several of the employee benefit programs. If you die without having designated a beneficiary, the default beneficiary provisions of the program will control. Refer to the Summary Plan Description for more information.

Pearson Inc. Welfare Benefit Plan: Login to the Pearson Portal to name your beneficiaries for the Basic and Supplemental Life, AD&D and Business Travel Accident insurances. If you are naming a trust as a beneficiary for any of these programs, you must complete a paper form instead. Click here to obtain the form.

Pearson Inc. Pension Plan: Login to the Pearson Portal to name your beneficiaries for the Pearson Inc. Pension Plan (also known as the “Pension Equity Plan” or “PEP”). If you are married and designating someone other than your spouse as sole beneficiary, you must submit a paper form with notarized spousal consent. Click here to obtain the form.

Pearson Retirement Plan [401(k)] and Employee Stock Purchase Plan: Login to the Empower Retirement website to designate your beneficiaries for the Pearson Retirement Plan and the Pearson Employee Stock Purchase Plan.

Change in Life Event:

Log into the Pearson Portal and go to Record Life Event and make changes to your benefits.

Claim Forms – Medical, Dental & Vision:

Anthem BlueCross and BlueShield
Cigna Medical

Delta Dental
MetLife Dental

Vision Plan – VSP Claim

Evidence of Insurability (EOI):

Supplemental Life EOI: Please contact Pearson People Services (PPS) via myHR (Ask HR a Question) or call 1-877-311-0948 to receive an Evidence of Insurability (EOI)/Statement of Health form mailed to your home. You will receive instructions on how to complete the form and send it directly to Metlife for processing. You will then be notified in the mail by Metlife if your application has been approved, denied or pended for further medical information.

Supplemental LTD – Online EOI Instructions & Application: Follow the instructions and links on this page to complete your on-line Supplemental Long-Term Disability EOI submission.

Flexible Spending Accounts (FSA):

WageWorks FSA Claim

Flexible Work Options:

Flexible Work Arrangements Proposal Worksheet: Use this form when contemplating a Flexible Work Option. It is recommended you review the Flexible Work Options Accountability Guide before completing the form.

Flexible Work Options Accountability Guide

Payroll Forms:

Form W4: Access ADP Self Service to complete your Federal and State W4 forms.

Pharmacy Benefits:

CVS Caremark: Use this form to order prescriptions by mail. (Note: All plans except Kaiser.)
CVS Caremark Prescription Drug Reimbursement Form: CVS Caremark Prescription Drug Reimbursement Form: Use this claim form when you must pay full price for a prescription drug at a pharmacy because:

Short-Term Disability:

UNUM STD/FMLA Claim Brochure and Authorization Form: Instructions on how to initiate a STD and/or FMLA claim with Unum.

Weight Watchers:

Weight Watchers Reimbursement Form 2016: Use this form to request your 50% rebate after achieving your program participation criteria. See the Weight Watchers section under Health Promotion for detailed instructions.