Human Resources

Forms

CONTACT

The World Bank
1818 H Street N.W.
Washington, DC 20433

hroperations@worldbank.org

Forms

Enclosed, please find useful forms on a wide variety of HR topics below, including G4 and G1 visa services, G5 visa services, medical benefits for CO, and medical insurance for HQ, life insurance, and more.

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org or phone 202-473-2222 or 5220+32222.

ACCESS TO SALARY, BENEFITS, & PENSION INFORMATION

F02298 Access to Salary, Benefits, Pension Information (CO, HQ)

ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

F01603 Designation of Insurance Beneficiary for CO Staff and Retirees (CO)

F01604 Designation of Insurance Beneficiary for HQ-based Staff

F02367 Country Office Appointments - Household, MBP, and Optional Group Term Life / Dependent Life / AD&D Insurance Enrollment

F02367A Country Office Appointments - Life Event Reporting and MBP / Group Term Life / Dependent Life / AD&D Insurance Enrollment Changes

Form - Accident Insurance (Bank Paid) Assignment of Ownership

Form - Accident Insurance (Optional) Assignment of Ownership

G00059 Examples of Beneficiary Designations

APPOINTMENT OFFER AND INITIAL PROCESSING

Conflict of Interest Guidelines for Global Secondment Program Participants

F00011 Personal History Form (PHF)

F00013 Registration for Eligible Dependents and Emergency Contacts for Special Assignment Appointments

F00014 Registration/Dependency/Emergency Contact for ETC/ETT Appointments

Form - British Embassy in Baghdad Declaration of Criminal Convictions

Form - British Embassy in Baghdad Security Clearance Request

Form - Government of Iraq Badge Request

G00045 Notes for STC/STT HQ Appointments

G00049 ETT/ETC Summary of Benefits and Important Notes for CO Staff

G00050 Notes for STT/STC CO Appointments

G00055 Summary of Benefits for Open and Term Staff in Country Office

G00061 ETT/ETC Summary of Benefits and Important Notes for HQ Staff

G00203 Summary of Benefits Open and Term Staff HQ

ASSIGNMENT

Relocation Insurance Coverage

BENEFITS ON STARTING OR ENDING APPOINTMENT

F00009 Request for Reimbursement of Relocation/Resettlement on Ending Employment

F00014 Registration/Dependency/Emergency Contact for ETC/ETT Appointments

G00203 Summary of Benefits Open and Term Staff HQ

DISABILITY PROGRAM

Form - Short-term Disability Claim

EMERGENCY TRAVEL OR EVACUATION

F02110 Certification or Reimbursement of Benefit Travel

EMPLOYMENT AUTHORIZATION

Form - I-566 - World Bank version of USCIS Interagency Record of Request

Form I-765, Application for Employment Authorization

EMPLOYMENT VERIFICATION REQUESTS

T00113 Net to Gross Salary (American Staff) Explanation Letter

T00114 Net to Gross Salary (Non-American Staff) Explanation Letter

EXPATRIATE BENEFITS

F00677 Education Benefit (School Certificate for Confirmation)

F02110 Certification or Reimbursement of Benefit Travel

G4 AND G1 VISA SERVICES

F00039 World Bank Group Overseas G4 Visa Request (RNGO)

F00040 Special Immigration Request

F00151 Correction of I-94 Card

F20034 Change of visa status from G4 visa to a different visa, I-566 Endorsement

Form - DS-160 - Department of State Nonimmigrant Visa Application (Renew/Request Visa outside US)

Form - I-566 - World Bank version of USCIS Interagency Record of Request

G5 VISA SERVICES

G5 Domestic Worker Information and Forms (page contains documents in English, French, Spanish, and Tagalog)

F00115 Contract for G5 Domestic Employees (English version)

Contract for G5 Domestic Employees (French Version)

Contract for G5 Domestic Employees (Spanish Version)

Contract for G5 Domestic Employees (Tagalog Version)

F00036 Termination of G5 Domestic Employee

State Department arrival form

F00041 Request for New G5 Employee

F00042 Code of Conduct Regarding Employment of G5 Employees

F00101 Extension of I-94 for G5 Domestic Employee

F00151 Correction of I-94 Card

F03233 Addendum to the G5 Employment Contract

F200023 G5 Employment Compliance Certification

Form - I-566 - World Bank version of USCIS Interagency Record of Request

Pre-Notification Form for G5 Requests

INSURANCE BENEFICIARIES

F01603 Designation of Insurance Beneficiary for CO Staff and Retirees

F01604 Designation of Insurance Beneficiary for HQ-based Staff

F200054 Designation of Life Insurance Beneficiary for Retirees

G00059 Examples of Beneficiary Designations

LIFE EVENTS REPORTING

LIFE INSURANCE

F01603 Designation of Insurance Beneficiary for CO Staff and Retirees

F01604 Designation of Insurance Beneficiary for HQ-based Staff

F02367 Country Office Appointments - Household, MBP, and Optional Group Term Life / Dependent Life / AD&D Insurance Enrollment

F02367A Country Office Appointments - Life Event Reporting and MBP / Group Term Life / Dependent Life / AD&D Insurance Enrollment Changes

F200054 Designation of Life Insurance Beneficiary for Retirees

Form - Cigna Evidence of Insurability Late Enrollment

Form - Cigna Group Life Insurance Portability Election Form

Form - Prudential Evidence of Insurability Late Enrollment (Short and Long Form)

Form - Prudential Financial: Absolute Gift Assignment to Individual

Form - Prudential Financial: Absolute Gift Assignment to Trustee

Form - Prudential Group Term Life Insurance Portability Election

Form - Prudential Short Form Health Statement Questionnaire

G00059 Examples of Beneficiary Designations

Guide - Cigna Group Life Insurance Plan Retiree Brochure

Guide - Cigna Group Life Insurance Portability Brochure

Guide - Prudential Portability Brochure

MEDICAL BENEFITS FOR CO (MBP)

F02367 Country Office Appointments - Household, MBP, and Optional Group Term Life / Dependent Life / AD&D Insurance Enrollment

F02367A Country Office Appointments - Life Event Reporting and MBP / Group Term Life / Dependent Life / AD&D Insurance Enrollment Changes

F02368 Retiree Life Event & MBP Enrollment Request

Form - Cigna Request for Continuation of Coverage for Handicapped Children

Form - Cigna Request for Prior Approval of Out-of-country Care

Form - Reimbursement Claim Form for Country Offices

G00209 Medical Benefits Plan (MBP) - A Guide to Preventative Care

Guide - MBP Cigna Membership Guide

Guide - MBP Cigna Summary of Benefits

MIP EyeMed Reimbursement of Vision Expenses - HQ

MEDICAL INSURANCE FOR HQ (MIP)

Cigna Dental Claim Form - International Claims

Cigna Dental Claim Form - US Claims

F00018 Retiree Medical Insurance Plan (RMIP): Non-U.S. National Health Plan (NHP) Transmittal Form

F00023 Retiree MIP Direct Deposit of Medical Insurance Claim Payments

F00032 Retiree MIP Medicare Reimbursements

F00996 Request For Movement Between Domestic and International Administrators For MIP

F01997 Enrollment and Payroll Deduction Authorization To Change MIP Enrollment (Bank/Bank Couple)

F200021 U.S. National Health Plan (Medicare) Transmittal Form

Form - 892 - MIP: Aetna Claim for Reimbursement of Medical and Hospital Expenses

Form - Aetna Handicapped Child Attending Physician's Statement

Form - Aetna Request for Continuation of Medical Coverage for Handicapped Child

Form - MIP - Evidence of Insurability Statement Medical Coverage Late Enrollment - For Sponsored Plan Only

Form - MIP Cigna Claim for Reimbursement of Medical and Dental Expenses

Form - Medical Insurance Plan: Cigna International Estimate of Hospitalization Costs

G00063 Medical Insurance Plan (MIP) A Guide to Preventative Care

PAYFLEX EFT FORM

REASSIGNMENT

G00174 Summary of Benefits Applicable to Locally Recruited Staff Recruited Across Countries

STAFF SELECTION

F00011 Personal History Form (PHF)

Form - British Embassy in Baghdad Declaration of Criminal Convictions

Form - British Embassy in Baghdad Security Clearance Request

Form - Government of Iraq Badge Request

G00045 Notes for STC/STT HQ Appointments

G00049 ETT/ETC Summary of Benefits and Important Notes for CO Staff

G00055 Summary of Benefits for Open and Term Staff in Country Office

G00061 ETT/ETC Summary of Benefits and Important Notes for HQ Staff

CONTACT

The World Bank
1818 H Street N.W.
Washington, DC 20433

hroperations@worldbank.org