Benefits Forms
| Healthcare & Life Insurance Enrollment Forms |
Purpose |
|---|---|
| Healthcare Benefits Enrollment/Change Form | Used to enroll in, change, or waive healthcare |
| 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 LEOFF Enrollment Form | LEOFF - Used to enroll in the LEOFF plan. |
| DRS LEOFF 2 Re-Employment Form | LEOFF 2 Retirees - returning to work |
| DRS Beneficiary Designation Form |
Used to designate beneficiaries. |
| DRS Premium Deduction Authorization |
Used to pay retiree medical premiums through your DRS account. |
| All other DRS Forms |
| Deferred Compensation Forms |
Purpose |
|---|---|
| Enroll or Make Changes |
Login to your online account to make changes or enroll for the first time. |
| Special Catch-Up Contribution | Contact Mike Ferguson or 509-385-7825 for assistance |
| Final Payouts | Contact HR directly for assistance |
| 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. |
|
Used to pay medical Premiums after-tax. |
|
| W-4 Form |
Used to withhold the correct amount of federal income tax from your pay. |