Benefits Forms

Healthcare & Life Insurance Enrollment Forms
 Purpose
Healthcare Benefits Enrollment/Change Form
 Used to enroll in, change, or waive healthcare benefits.
Life Insurance & LTD Enrollment/Change Form
 Used to enroll in or change LTD and life Insurance.
Life Insurance Beneficiary Designation Form
 Designate beneficiaries for Life and AD&D insurance.
Medical & Dental Insurance Forms
 Purpose
Regence Direct Member Reimbursement Form
 Used to submit a claim for reimbursement.
Regence 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.
Delta Dental of WA Disabled Dependent Form
 Used to add a disabled child to your dental plan.
Retirement Forms
 Purpose
DRS Retirement Status Verification Form
 Used to document the retirement status of new employees.
DRS Member Information Form PERS - Used to enroll in a PERS plan.
DRS Enrollment Form LEOFF - Used to enroll in the LEOFF plan.
DRS Beneficiary Designation Form
 Used to designate beneficiaries.
Medical Prepaid Premiums Worksheet
 Used to pay for Regence Retiree Medical Insurance premiums with excess leave.
DRS Premium Deduction Authorization
 Used to pay retiree medical premiums through your DRS account.
All other DRS Forms  
Deferred Compensation Forms
 Purpose
Deferred Compensation Enrollment Form
 Contact Mike Ferguson for guidance fergusm9@nationwide.com
Deferred Compensation Change Form
 Used to change your current contributions with Nationwide.
Name/Address/Beneficiary Update Form
 Used to update your personal information with Nationwide.
Unforeseeable Emergency Distribution Application
 Used to request an Emergency Distribution.
Request for Purchase of Service Credit
Used to request purchase of service credits for retirement.
Disbursement Request - Nationwide
 Used to request disbursement after you leave employment.
Beneficiary Update Form - Empower
 Used to update beneficiaries with Empower-Retirement (previous plan).
Flexible Spending Account (FSA) Forms
 Purpose
FSA Enrollment Form - New Hires Used to enroll in a FSA - new hires or 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
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.
Life Insurance and AD&D Claim Form
 Used to submit a death, accidental death, dismemberment and/or injury claim.
Long Term Disability (LTD) Forms
 Purpose
Long Term Disability Claim Form
 Used to submit a LTD claim.
Aflac Forms
 Purpose
Enroll in Aflac policies Visit the Aflac webpage for details.
Initial Disability Claim Form
 Used to initiate a Short Term Disability claim.
Accident Wellness Benefit Claim Form
 Used to submit a wellness claim.
Accidental Injury Claim Form
 Used to submit an accident/injury claim.                        
Other Forms
 Purpose
Remove Dependent Form
 Used to remove a dependent from your benefits.
Waiver of Benefits
 Alternative method to waive or cancel benefits.

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).
W-4 Form
 Used to withhold the correct amount of federal income tax from your pay.