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. |
Used to submit a change in your name, address, phone number and emergency contacts. |
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Used to add a Domestic Partner to your benefits. |
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Used to pay medical Premiums after-tax. |
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Used to cancel certain voluntary payroll deduction(s). |
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W-4 Form |
Used to withhold the correct amount of federal income tax from your pay. |