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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.