Forms -- NEISD.net

  NEISD Employee Benefits Forms

For New Hires and Family Status Changes Outside of Open Enrollment,
Click on the form needed, complete, print and send to Employee Benefits.


Click on the form needed, fill it out, print then Fax it to 804-7014

**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.

American Natl - Enrollment Form

Life Insurance enrollment form.  Evidence of Insurability must be completed (page 2).

American Natl - Change Form

Beneficiary, name, method of settlement changes.
Read instructions on page 2 before comleting this form.

   
   

Cafeteria Plan Election Form **For New Hires

Use this form to have your premiums either pre-tax or taxable. Use this form for Open Enrollment 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.

Dental Enrollment/Change Form **For New Hires and Family Status Changes Only

New enrollee, add, cancel dependents.  If premium is on the Cafeteria Plan, complete the Cafeteria Plan Election Change form also.

Designation of Beneficiary - TRS

Updates TRS beneficiary only.

Flexible Spending Enrollment Form For new enrollments and Family Status Changes.
Flexible Spending Change Forms For Family Status Changes
Mail Order Prescription Form Order your prescriptions through our mail order program
MetLife 401(a) change form This form is to be used by current participants only. For personal information changes.
MetLife 457(b) change form This form is to be used by current participants only. For personal information changes.
Prescription Reimbursement Claim Form Members with pharmacy benefits through Blue Cross and Blue Shield of Texas 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.
Health Insurance Enrollment Form --For New Employees and Special Enrollment events. NEISD Notice of Enrollment or Change in Health Coverage. Please complete the Cafeteria Plan Election Change Form if you elect to have your premium on the Cafeteria Plan.

Hospital Indemnity Claim Form

$250 per day reimbursement for inpatient hospital confinement.

$10,000 Life Insurance Beneficiary Change Form

Designation of beneficiary for the $10,000 life insurance.

Catastrophic Sick Leave Bank Application - Sick Days Complete page 1, instructions on page 2. Physicians Statement must accompany Catastrophic Sick Leave Bank Application

Catastrophic Sick Leave Bank Physician's Statement

Complete page 1, instructions on page 2. Application for days must accompany physicisan's statement.

Sick Leave Bank Enrollment Form

Enrollment form to join the Sick Leave Bank.

Student Dependent Certification To continue coverage beyond the max age limit this form must be rec'd within 60 days of the affected dependent becoming eligible.

Tax Sheltered Announts (403b)

Salary Reduction Agreement & Disclaimer Statement - 403b, Tax Sheltered Annuity please call JEM at 1-800-943-9179 or go to www.jemtpa.com

UnumProvident Application for Coverage.

UNUM's New Employee/ Open Enrollment form. For new (within first 60 days of employment and existing/current employees during Open Enrollment (August 1st through 31st).

UNUMProvident Disability Claim Form

For employees who wish to make a benefit claim