Benefit Forms
New Enrollment/Qualifying Event Forms
- Group Benefit Enrollment/Change Form
- Flexible Spending Enrollment/Change Form
- Life Insurance Enrollment/Change Form
- Life Insurance Beneficiary/Designation Change Form
- Medical History Form (Online Process)
- Medical History Form (Paper Version)
- Declaration of Domestic Partner Relationship Form
- Domestic Partner Dissolution Form
Legislator Forms
Reimbursement Forms
- URx Direct Member Reimbursement Form
- EyeMed Out-of-network Claim Form
- Medically Necessary Contact Lenses - Fill out to determine reimbursement for Medically Necessary Contacts
- Allegiance Flex Advantage Medical Expense Reimbursement Request Form
- Day Care Reimbursement Request Form
- Blue Cross Blue Shield (Traditional or Blue Choice) Flu Shot reimbursement form
Pharmacy Mail Order Forms
Pharmacy Forms
Declaration of Tax Status Form
Authorization Forms
Pre-Retirement Forms
- Retiree Election Form
- Retiree Election Form Example
- Pre-Payment Option Form
- Electronic Payment Deduction Authorization Form
- Standard Portability Insurance Form
- Conversion Information
COBRA Forms
Sick Leave Pool Forms
- Sick Leave Fund Contribution procedures and form, .pdf or .doc
- Sick Leave Fund Request procedures and form, .pdf or .doc
- Direct Grant procedures and form, .pdf or .doc
- Long-Term Disability policy
- Accidental Death and Dismemberment policy
- Life Insurance policy
- Long-Term Care Policy
Life Insurance Claim Forms
