Click on the form needed, complete, print and send to Employee Benefits.
**All requests for changes
to benefits must be received within 31 calendar days of the qualifying event.
In the event that the 31st day falls
on a weekend or holiday, (including closed business days), requests must be
received on the last working day prior to your 31st day.
***TSA enrollment/changes can be made at anytime throughout
the year.
| Cancellation Form-Life, Disability, Cancer, and Vision | To cancel benefits that are not on the Cafeteria Plan (pre-taxed) |
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When to use |
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| Cancer Enrollment Application | New Enrollment or change in coverage |
| Wellness Claim Form | Filing a wellness claim for exam performed |
| Cancer Change Form | Changes to existing Cancer coverage |
| Claim Form | Filing cancer/specified disease/ICU/Heart/Stroke Claims |
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When to use |
When to use |
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Enrollment form to join the Sick Leave Bank. |
Dental Enrollment/Change Form **For New Hires and Family Status Changes Only |
New enrollees, add, cancel dependents. If premium is on the Cafeteria Plan, complete the Cafeteria Plan Election Change form also. |
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Complete page 1, Application for days must accompany Physician's statement. |
Cafeteria Plan Election Form **For New Hires |
Use this form to have your premiums either pre-tax or taxable. |
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| Sick Leave Bank Application - Sick Days | Complete page 1, Physicians Statement must accompany Sick Leave Bank Application for days. |
Cafeteria Plan Election Change **For Family Status Changes only |
Complete this form to make changes to your benefit selections already on the Cafeteria plan when you experience a family status change outside of the Open Enrollment period. |
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When to use |
When to use |
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New Employee Enrollment form (within first 60 days of employment). |
$250 per day reimbursement for inpatient hospital confinement. |
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| Disability
Claim Form |
For employees who wish to make a benefit claim | ||
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Incentive Program |
When to use |
When to use |
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| MetLife 401(a) change form | This form is to be used by current participants only. For personal information changes. | Life Insurance enrollment form. For Family Status Changes. | |
| MetLife Beneficiary Designation-401(a) | Beneficiary changes for participants |
Beneficiary changes. |
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| MetLife Annuity Claim Form | To claim 401(a) district deposits |
Updates TRS beneficiary only. |
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Designation of beneficiary for the $10,000 life insurance. |
| Medical | When to use | Section 125 (cafeteria/FSA) | When to use |
| Health Insurance Enrollment Form | New Enrollment or Change in Health Coverage. Complete the Cafeteria Plan Election Change Form if you elect to have your premium on the Cafeteria Plan. |
Use this form to have your premiums either pre/post-taxed. |
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Use this form to have your premiums either pre/post taxed. |
Complete this form to make changes to your benefit selections when you experience a family status change outside of the Open Enrollment period. |
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Complete this form to make changes to your benefit selections when you experience a family status change outside of the Open Enrollment period. |
Flexible Spending Change Forms | For Family Status Changes to your FSA account. | |
| Mail Order Prescription Form | Order your prescriptions through our mail order program | Flexible Spending Enrollment Form | For new enrollments. |
| Prescription Reimbursement Claim Form | Members
with pharmacy benefits through BC/BS can use this form to file pharmacy
claims for reimbursement. This form is to be used for those participants who have not received a membership card and must pay out of pocket. |
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| Tax Sheltered Accounts | When to use | Vision Plan | When to use |
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Salary Reduction Agreement & Disclaimer Statement - 403b, Tax Sheltered Annuity. |
Enrollment Form **For New Hires and Family Status Changes only. |
New Enrollment or Change in Coverage. Complete the Cafeteria Plan Election Change Form if you elect to have your premium on the Cafeteria Plan. | |
| MetLife 457(b) change form | This form is to be used by current participants only. For personal information changes. |
Use this form to have your premiums either pre-tax or taxable. |
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| MetLife 401(a) change form | This form is to be used by current participants only. For personal information changes. |
Cafeteria Plan Election Change **For Family Status Changes only |
Complete this form to make changes to your benefit selections already on the Cafeteria plan when you experience a family status change outside of the Open Enrollment period. |
| MetLife 457(b) beneficiary change form | Beneficiary changes for participants |