Benefit Forms

Regence Forms - Group # 10008695

Purpose

Regence Enrollment Form (*Also used for Vision) Used to enroll in medical and/or vision coverage.
Regence Direct Member Reimbursement Form Used to submit a claim for reimbursement.
Regence OptumRx New Prescription Mail Order Form Used to order a new mail order prescription.
Regence Affidavit of Qualifying Incapacitated Dependent Form Used to add incapacitated dependent to the plan.

Group Health Forms

Group #

CategorIes

Group Health Alliant Plus Enrollment Form 5910400         A, B, C, E, & I                                              
Group Health Options Enrollment Form (LEOFF) 0617700 D & G
Group Health Options Enrollment Form 6432900 F & H
Group Health Rx Mail Order Forms    

Dental Forms

Group #

Purpose

Delta Dental of WA PPO Enrollment Form #00444                 Used to enroll in the PPO plan.
Delta Dental of WA Delta Care Enrollment Form #00114 Used to enroll in the DeltaCare plan.
Willamette Dental Group Enrollment Form #WA175 Used to enroll in the Willamette plan.
Delta Dental Disabled Dependent Verification Form   Used to add a disabled dependent to the plan.

Retirement Forms

Purpose

DRS Member Information Form Used to enroll in a DRS retirement plan.                                                         
DRS Beneficiary Form Used to designate beneficiaries.
Medical Prepaid Premiums Worksheet Used to pay for Regene Reitree Medical Insurance premiums with excess leave.
DRS Premium Deduction Authorization Used to pay retiree medical premiums through your DRS account.
All other DRS Forms Use to access all other DRS forms. 

Deferred Compensation Forms

Purpose

Deferred Compensation Enrollment Form Used to enroll. Contact Mike Ferguson for guidance fergusm9@nationwide.com
Deferred Compensation Change Form Used to change your current contributions.
Name/Address/Beneficiary Update Form Used to update your personal information with Nationwide.
Unforeseeable Emergency Withdrawal Request Used to request an emergency withdrawal. Click here for guidance. 
Request for Purchase of Service Credit Used to request purchase of service credits for retirement.
Nationwide Disbursement Request  Used to request disbursement after you leave employment.

Nationwide Rollover Request

Used to request a rollover.

Flexible Spending Account (FSA) Forms

Purpose

New Hire FSA Enrollment Form / Instructions Used to enroll in a FSA - newly eligible employees.
FSA Claim Form Used to manually submit a FSA claim.
Daycare FSA Recurring Claim Form Used to set up a recurring daycare claim.
FSA Letter of Medical Necessity Used to provide proof of medical necessity.
FSA Change in Status Form Used to change current FSA elections due to a change in status or LWOP.
FSA Termination Form Used to terminate your FSA when you leave the County.

Hartford Life Insurance Forms

Purpose

Basic Life & AD&D Insurance Enrollment Form Used to enroll in Basic Life Insurance and AD&D Insurance. 
Supplemental Life Insurance Enrollment and Change Form Used to enroll in (or make changes) Supplemental Life Insurance.
Life Insurance Beneficiary Designation Form Used to designate beneficiaries.
Personal Health Application Used to provide Evidence of Insurability for Supplemental Life.
Waiver of Premium Form Used to waive premiums when disabled/unable to work.
Notice of Continuation of Coverage Used to request to continue your coverage when you leave employment.

Children with Disabilities Eligibility Form

Used to add a disabled child to your Supplemental Life Insurance.
Life Insurance Claim Form Used to submit a death claim.

AIG Accidental Death and Dismemberment (AD&D)

Purpose                                

AIG AD&D Enrollment Form

Used to enroll in additional AD&D Insurance.

AIG AD&D Beneficiary Form

Used to designate optional AIG AD&D beneficiaries.
AIG Accidental Dismemberment Claim Form

Used to submit a claim for an accident.

AIG Accidental Death Claim Form Used to submit a claim for an accidental death.

Long Term Disability (LTD) Forms

Purpose

Long Term Disability Enrollment Form Used to enroll in LTD.
Long Term Disability Claim Form Used to submit a LTD claim.

Aflac Forms

Purpose

Enroll in Aflac policies Visit the Aflac webpage for details.
Accident Wellness Benefit Claim Form Used to submit a wellness claim.
Accidental Injury Claim Form Used to submit an accident/injury claim.                        
Cancer Claim Form Used to submit a cancer claim.
Cancer Screening Wellness Claim Form Used to submit a cancer screening claim. 
Hospital Indemity Wellness Claim Form Used to submit a hospital indemnity claim.
Initial Disability Claim Form Used to submit  a disabilty claim.
Continuing Disability Claim Form Used to submit a continuing disabilty claim.
Sickness Claim Form  Used to submit a sickness claim. 

Benefit Forms

Purpose

Add Dependent Form

Used to add dependent(s) to your benefits. Click here for guidelines.

Remove Dependent Form Used to remove dependent(s) from your benefits. Click here for guidelines.

Personal Information Update Form

Used to submit a change in your name, address, phone number and emergency contacts.

Affidavit of Domestic Partnership

Used to add a Domestic Partner to your benefits.

Waiver of Pretax Medical Premiums

Used to pay medical Premiums after-tax.

Cancellation of Voluntary Deductions

Used to cancel certain voluntary payroll deduction(s).

Waiver of Healthcare Coverage Used to waive healthcare insurance. (Regular employees)
Waiver of Medical Insurance Used to waive medical insurance. (Temporary/Seasonal employees)
W-4 Used to withhold the correct amount of federal income tax from your pay.
All other payroll forms: Click here to access all other payroll forms.