Health Care & Benefits Division
Benefit Enrollment
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
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
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 Form
Retiree Payment Options Forms
- Electronic Benefits Deduction Authorization Form
- MPERA Authorization for Deduction of Benefits Payments
Surviving Dependent Forms
Benefit Administration
Authorization Forms
Flexible Spending Forms
Life Insurance Forms
- Conversion Application
- Evidence of Insurability
- Portability Application
- Portability & Conversion Comparison
Pharmacy Forms
-
Costco Prescription Drug Mail Order Form (Membership Not Required)
- miRx Prescription Drug Mail Order Form
- Navitus Direct Member Reimbursement Claim Form
- Ridgeway Prescription Drug Mail Order Form
Other Benefit Forms
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
More information about the Healthy Weight Incentive
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