Benefits Forms
| 2019 Open Enrollment Forms and Charts | Purpose |
|---|---|
| Healthcare Benefits Form - Open Enrollment 2019 | Used to enroll in, change, or waive healthcare benefits during Open Enrollment |
| Medical Plans ABCEI | Medical insurance comparison chart for Categories A, B, C, E, & I. Effective 4/1/2019. |
| Medical Plans DG | Medical insurance comparison chart for Categories D & G. Effective 4/1/2019. |
| Medical Plans FH | Medical insurance comparison chart for Categories F & H. Effective 4/1/2019. |
| Dental Plans | Dental insurance comparison chart. Effective 4/1/2019. |
| Vision Plan | Vision insurance summary chart. Effective 4/1/2019. |
| FSA Enrollment Form - Open Enrollment 2019 | Used to enroll/re-enroll in a FSA during Open Enrollment. |
| Healthcare & Life Insurance Enrollment Forms |
Purpose |
|---|---|
| Healthcare Benefits Enrollment/Change Form (PDF) |
Used to enroll in, change, or waive healthcare benefits. |
| Life Insurance & LTD Enrollment/Change Form (PDF) |
Used to enroll in or change LTD and life Insurance. |
| Life Insurance Beneficiary Designation Form (PDF) |
Designate beneficiaries for Life and AD&D insurance. |
| Medical & Dental Insurance Forms |
Purpose |
|---|---|
| Regence Direct Member Reimbursement Form (PDF) |
Used to submit a claim for reimbursement. |
| Regence Prescription Mail Order Form (PDF) |
Used to order a new mail order prescription. |
| Regence Affidavit of Qualifying Incapacitated Dependent Form (PDF) |
Used to add incapacitated dependent to the plan. |
| Delta Dental of WA Disabled Dependent Form (PDF) |
Used to add a disabled child to your dental plan. |
| Retirement Forms |
Purpose |
|---|---|
| DRS Retirement Status Verification Form (PDF) |
Used to document the retirement status of new employees. |
| DRS Member Information Form (PDF) |
PERS - Used to enroll in a PERS plan. |
| DRS Enrollment Form (PDF) |
LEOFF - Used to enroll in the LEOFF plan. |
| DRS Beneficiary Designation Form (PDF) |
Used to designate beneficiaries. |
| Medical Prepaid Premiums Worksheet (PDF) |
Used to pay for Regence Retiree Medical Insurance premiums with excess leave. |
| DRS Premium Deduction Authorization (PDF) |
Used to pay retiree medical premiums through your DRS account. |
| All other DRS Forms |
| Deferred Compensation Forms |
Purpose |
|---|---|
| Deferred Compensation Enrollment Form (PDF) |
Contact Mike Ferguson for guidance [email protected] |
| Deferred Compensation Change Form (PDF) |
Used to change your current contributions with Nationwide. |
| Name/Address/Beneficiary Update Form (PDF) |
Used to update your personal information with Nationwide. |
| Unforeseeable Emergency Distribution Application (PDF) |
Used to request an Emergency Distribution. |
| Request for Purchase of Service Credit (PDF) |
Used to request purchase of service credits for retirement. |
| Disbursement Request - Nationwide (PDF) |
Used to request disbursement after you leave employment. |
| Beneficiary Update Form - Empower (PDF) |
Used to update beneficiaries with Empower-Retirement (previous plan). |
| Flexible Spending Account (FSA) Forms |
Purpose |
|---|---|
| FSA Enrollment Form - New Hires (PDF) | Used to enroll in a FSA - new hires or newly eligible employees. |
| FSA Claim Form (PDF) |
Used to manually submit a FSA claim. |
| Daycare FSA Recurring Claim Form (PDF) |
Used to set up a recurring daycare claim. |
| FSA Letter of Medical Necessity (PDF) |
Used to provide proof of medical necessity. |
| FSA Change in Status Form (PDF) |
Used to change current FSA elections due to a change in status or LWOP. |
| FSA Termination Form (PDF) |
Used to terminate your FSA when you leave the County. |
| Hartford Life Insurance Forms |
Purpose |
|---|---|
| Personal Health Application (PDF) |
Used to provide Evidence of Insurability for Supplemental Life. |
| Waiver of Premium Form (PDF) |
Used to waive premiums when disabled/unable to work. |
| Notice of Continuation of Coverage (PDF) |
Used to request to continue your coverage when you leave employment. |
| Life Insurance Claim Form (PDF) |
Used to submit a death claim. |
| AIG Accidental Death & Dismemberment (AD&D) |
Purpose |
|---|---|
| AIG Accidental Dismemberment Claim Form (PDF) |
Used to submit a claim for an accident. |
| AIG Accidental Death Claim Form (PDF) |
Used to submit a claim for an accidental death. |
| Long Term Disability (LTD) Forms |
Purpose |
|---|---|
| Long Term Disability Claim Form (PDF) |
Used to submit a LTD claim. |
| Aflac Forms |
Purpose |
|---|---|
| Enroll in Aflac policies | Visit the Aflac webpage for details. |
| Initial Disability Claim Form (PDF) |
Used to initiate a Short Term Disability claim. |
| Accident Wellness Benefit Claim Form (PDF) |
Used to submit a wellness claim. |
| Accidental Injury Claim Form (PDF) |
Used to submit an accident/injury claim. |
| Other Forms |
Purpose |
|---|---|
| Remove Dependent Form (PDF) |
Used to remove a dependent from your benefits. |
| Waiver of Benefits (PDF) |
Alternative method to waive or cancel benefits. |
Used to submit a change in your name, address, phone number and emergency contacts. |
|
Used to add a Domestic Partner to your benefits. |
|
Used to pay medical Premiums after-tax. |
|
Used to cancel certain voluntary payroll deduction(s). |
|
| W-4 Form (PDF) |
Used to withhold the correct amount of federal income tax from your pay. |
| All other payroll forms |