Health Care and Benefits Division

Forms

Annual Change

New Employee
Employee
Declaration of Tax Status
Legislators
Retirees
Cobra Members
Adding Dependents

Joint Core

Summary Plan Document
Blue Choice Supplement
New West Supplement
PEAK Supplement
Administrator Contacts

Goals and Objectives

Wellness
Current Newsletter (PDF)
Benefits Council (SEGBAC)
VEBA
Total Comp Statement

Workers' Compensation Management Bureau
Employee Safety Program
Early Return to Work
Sick Leave Fund

HCBD Staff

Benefit Forms

New Enrollment/Qualifying Event

• 2008 GroupBenefit Enrollment/Change Form Word/PDF
• 2008 Flexible Spending Enrollment/Change Form Word/PDF
• Life Insurance Enrollment/Change Form (pdf)
• Evidence of Insurability (Medical History Form)
• Declaration of Domestic Partner Relationship Form
• Domestic Partner Dissolution Form
  
  Reimbursement Forms
  
• Caremark Direct Member Reimbursement Form (pdf)
• ASI Flexible Spending Claim Form (pdf)
• EyeMed Out-of-network Claim form
  
  Pharmacy Mail Order
  
• Ridgeway Prescription Drug Mail Order Form (pdf)
• CaremarkPrescription Drug Mail Order Form (pdf)
  
  Authorization Forms
  
• BCBS out of state travel preauthorization form
• HIPAA Privacy Notice and Authorization Form (pdf)
  
  Active Duty Forms
  
• Instructions
• Insurance Election form
• Insurance Reinstatement form
  
  Pre-Retirement Forms
  
• Retiree Election Form (pdf)
• Retiree Election Form (Example) (pdf)
• Pre-Payment Option Form (pdf)
  
  Certificates and Policies
  
• Long Term Disability Certificate
• Accidental Death and Dismemberment policy
• Life Insurance Certificate