Human Resources and Employee Benefit Forms

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​These are all of the forms that you may need to take advantage of your employee benefits, as well as other helpful Human Resources forms. For an overview of employee benefits, view the benefits overview course. Find links to detailed information about benefits for your specific employee group from the jobs page.

Title (with link to item)File SizeType
2018 Flexible Spending Accounts Enrollment or Waiver Form204 KBflexible-spending-accounts-enrollment-or-waiver-form.pdf
2018 Health Savings Account (HSA) Enrollment Form175 KBhsa-enrollment-form.pdf
2019 Open Enrollment Flexible Spending Account (FSA) Enrollment form195 KB2019-open-enrollment-flexible-spending-account-enrollment-form.pdf
2019 Open Enrollment Flexible Spending Limited Purpose Enrollment Form130 KB2019-open-enrollment-flexible-spending-limited-purpose-enrollment-form.pdf
2019 Open Enrollment Health Insurance Enrollment, Change Form170 KB2019-open-enrollment-health-insurance-enrollment-form.pdf
2019 Open Enrollment Health Savings Account (HSA) Enrollment form173 KB2019-open-enrollment-health-savings-account-enrollment-form.pdf
Additional AD&D Insurance Enrollment Beneficiary Form183 KBadditional-add-insurance-enrollment-beneficiary-form.pdf
Additional Life Insurance Enrollment Beneficiary Form69 KBadditional-life-insurance-enrollment-beneficiary-form.pdf
Birth Certificate Verification form202 KBbirth-certificate-verification-form.pdf
City Paid Life and AD&D Insurance Beneficiary Form289 KBcity-paid-life-and-add-insurance-beneficary-form.pdf
Commute Expense Reimbursement Account CERA Claim Form125 KBcommute-expense-reimbursement-account-cera-claim-form.pdf
Commute Expense Reimbursement Account CERA Enrollment form103 KBcommute-expense-reimbursement-account-cera-enrollment-form.pdf
Disabled Dependent Certification form459 KBdisabled-dependent-certification-form.pdf
Domestic Partner Affidavit form89 KBdomestic-partner-affidavit-form.pdf
Domestic Partner Termination form72 KBdomestic-partner-termination-form.pdf
EBMS - Medical and Vision Claim Form131 KBebms-medical-vision-claim-form.pdf
Electronic Disclosure Form135 KBelectronic-disclosure-form.pdf
Employee Address Change form153 KBhr-047-employee-address-change-form.pdf
Employee or Dependent Name Change form153 KBhr-063-employee-or-dependent-name-change-form.pdf
Employee Request for Accomodation Form - ADA1240 KBhr-034-employee-request-for-accommodation-form-ada.pdf
Flexible Spending Accounts Claim Form55 KBflexible-spending-accounts-claim-form.pdf
Flexible Spending Accounts Mid Year Change Form118 KBflexible-spending-accounts-mid-year-change-form.pdf
Health Care Provider - Serious (Family)60 KBhr-020-protected-leave-family-serious-cert.pdf
Health Care Provider - Serious (Self)143 KBhr-019-protected-leave-health-care-provider-serious-self.pdf
Health Hub Service Agreement Form168 KBhealth-hub-service-agreement-form.pdf
Health Insurance Coordination of Benefits143 KBhealth-insurance-coordination-of-benefits-form.pdf
Health Insurance Enrollment Form170 KBhealth-insurance-enrollment-form.pdf
Health Insurance Opt-Out Waiver Incentive Form169 KBhealth-insurance-opt-out-waiver-incentive-form.pdf
HRA VEBA Election Form2542 KBhra-veba-election-form.pdf
Incident Report Form571 KBincident-report-form.pdf
Life and Long Term Disability Form314 KBlife-and-long-term-disability-form.pdf
Medical Provider Inquiry Form - ADA1240 KBhr-035-medical-provider-inquiry-form-ada.pdf
Military Exigency Leave61 KBhr-021-protected-leave-military-extgency-leave.pdf
Military Family Leave68 KBhr-022-protected-leave-serious-military-family.pdf
Optum RX Mail Order Prescription Form497 KBoptum-rx-mail-order-prescription-form.pdf
Optum RX Member Reimbursement Form101 KBoptum-rx-member-reimbursement-form.pdf
PERS IAP Beneficiary Form634 KBpers-iap-beneficiary-form.pdf
PERS Tier 1 or Tier 2 Beneficiary Form1239 KBpers-tier-1-or-tier-2-beneficiary-form.pdf
Protected Leave Application117 KBhr-017-protected-leave-application.pdf
Release of Health Information104 KBhr-018-protected-leave-release-of-health-information.pdf
Release to Return to Work48 KBhr-026-release-to-return-to-work.pdf
Veteran Military Caregiving Leave120 KBhr-023-protected-leave-veteran-care.pdf
Voya - EZ Enrollment Form482 KBvoya-ez-enrollment-form.pdf
Voya - Final Paycheck Deferral Form42 KBvoya-final-paycheck-deferral-form.pdf
Voya - Holiday Cash Out Deferral Form42 KBvoya-holiday-cash-out-deferral-form.pdf

Contact us

Michele BennettHuman Resources ManagerCarrie WagnerHuman Resources SpecialistHuman Resources Department
Monday–Friday
8:00 a.m.–5:00 p.m.
555 Liberty ST SE RM 225
Salem OR 97301
Phone: 
503-588-6162Human Resources main line503-589-2085Carrie Wagner's direct line