All employee elections are completed online.

• New Employee Enrollment Information
• Newly Eligible Online Enrollment Instructions
• Mid Year Change Enrollment Instructions
• Mid Year Change Information

Active Duty Military Leave Forms

• Active Duty Military Leave Election Form
• FAQ About Military Leave

Domestic Partnership/Common Law Marriage Forms

• Affidavit of Common Law Marriage
• Declaration of Domestic Partner Relationship Form
• Dissolution of Domestic Partner Relationship Form

Legislator Forms

• Legislator Opt Out/Waiver Form
• New Legislator Enrollment Form

Reduction in Force (RIF) Forms

• Reduction in Force (RIF) Prepayment Option Form (Agency Use Only)

Pre-Retirement Forms

• Conversion Application
• Life Insurance Beneficiary Designation Form
• Portability Application
• Portability & Conversion Comparison 
• Retiree Election and Prepayment Option Form (Agency Use Only)

Retiree Forms

• Retiree Primary Plan Member Change Form
• Retiree Termination Form

Retiree Payment Options Forms

• Electronic Benefits Deduction Authorization Form
• MPERA Authorization for Deduction of Benefits Payments

Surviving Dependent Forms

• Surviving Dependent Election Form

Authorization Forms

• Allegiance Authorization to Release Confidential Health & Claim Information
• Cigna Authorization for Disclosure of PHI
• HIPAA Privacy Notice and Authorization 
• Member Complaint Report Form

Flexible Spending Forms

• Automatic Reimbursement Request Form
• Flex Medical Expense Reimbursement Request

Life Insurance Forms

• Conversion Application 
• Evidence of Insurability
• Portability Application
• Portability & Conversion Comparison 

Pharmacy Forms

• Costco Prescription Drug Mail Order Form (You do not need to be a Costco member)
• miRx Prescription Drug Mail Order Form
• Navitus Direct Member Reimbursement Claim Form
• Ridgeway Prescription Drug Mail Order Form

Reimbursement Forms

• Allegiance Claim Form (Paper)
• Allegiance Online Claim Form (Electronic)
• Cigna Vision Claim Form
• Weight Watchers Reimbursement form

Sick Leave Fund and Direct Grant Forms

• Direct Grant Procedure & Form
• Sick Leave Fund Contribution Procedure & Form
• Sick Leave Fund Grant Request Procedure & Form
• Sick Leave Fund Policy

Healthy Weight Incentive Application Forms
More information about the Healthy Weight Incentive

• WW Incentive Application Form
• Healthy for Life Incentive Application Form
• Diabetes Prevention Program Incentive Application Form