Benefit Forms

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
 (PDF)FSA Enrollment Form - New Hires Used to enroll in a FSA - new hires or newly eligible employees.
Open Enrollment FSA Enrollment Form (PDF)
Used to enroll/re-enroll in a FSA during Open Enrollment.
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.

Personal Information Update Form (PDF)

Used to submit a change in your name, address, phone number and emergency contacts.

Affidavit of Domestic Partnership (PDF)

Used to add a Domestic Partner to your benefits.

Waiver of Pretax Medical Premiums (PDF)

Used to pay medical Premiums after-tax.

Cancellation of Voluntary Deductions (PDF)

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