Forms - Health Care & Benefits Division
Forms
Forms requiring a digital signature will need to be downloaded to your computer and opened in Adobe Acrobat or Adobe Reader for the signature field(s) to work properly.
All employee elections are completed online.
- New Employee Enrollment Information
- Newly Eligible Online Enrollment Instructions
- Mid Year Change Enrollment Instructions
- Mid Year Change Information
Active Duty Military Leave Forms
Domestic Partnership/Common Law Marriage Forms
- Affidavit of Common Law Marriage
- Declaration of Domestic Partner Relationship & Affidavit of Shared Residence Form
- Dissolution of Domestic Partner Relationship Form
Legislator Forms
Reduction in Force (RIF) Forms
- RIF Prepayment Option Form (Agency Use Only)
Pre-Retirement Forms
- Conversion Application
- Life Insurance Beneficiary Designation Form
- Portability Application
- Portability & Conversion Comparison
- Retiree Election & Prepayment Option Form (Agency Use Only)
Retiree Form
Retiree Payment Options Forms
- Electronic Benefits Deduction Authorization Form
- MPERA Authorization for Deduction of Benefits Payments
Surviving Dependent Forms
Authorization Form
Flexible Spending Accounts (FSAs) Forms
Life Insurance Forms
- Conversion Application
- Evidence of Insurability
- Portability Application
- Portability & Conversion Comparison
Pharmacy Form
Sick Leave Fund and Direct Grant Forms
- Direct Grant Procedure & Form
- Sick Leave Fund Contribution Procedure & Form
- Sick Leave Fund Grant Request Procedure & Form
- Sick Leave Fund Policy