Benefit Forms

​For an overview of employee benefits, view the benefits overview course.

​Employee Benefit Forms

  
  
  
2018 FSA Election Form147 KBfsa-election-form-open-enrollment-2018.pdf
2018 FSA Limited Purpose Election Form121 KBfsa-limited-purpose-election-form-open-enrollment-2018.pdf
2018 HSA Payroll Election Form142 KBhsa-payroll-election-form-2018.pdf
2018 Opt-Out Incentive Waiver Form130 KBopt-out-incentive-waiver-form-2018.pdf
Additional AD&D Policy70 KBadditional-add-policy.pdf
Additional AD&D Summary36 KBadditional-add-summary.pdf
Additional Life Policy186 KBadditional-life-policy.pdf
Additional Life Summary201 KBadditional-life-summary.pdf
City Paid Life and AD&D Insurance Beneficiary289 KBcity-paid-life-and-add-insurance-beneficary-form.pdf
Dental Claim Form653 KBdental-claim-form.pdf
EBMS - Medical, Dental, and Vision Form131 KBebms-medical-vision-claim-form.pdf
Electronic Disclosure Form33 KBelectronic-disclosure-form.pdf
FSA - Claim Form55 KBfsa-claim-form.pdf
FSA - Enrollment Authorization Form189 KBflexible-spending-enrollment-authorization-form.pdf
FSA - Mid Year Change Form118 KBfsa-mid-year-change-form.pdf
FSA - Orthodontia Contract Form34 KBfsa-orthodontia-contract-form.pdf
Health Enrollment Change of Information121 KBhealth-enrollment-change-of-information-form.pdf
Health Insurance Enrollment Form123 KBhealth-insurance-enrollment-form.pdf
HRA VEBA Election Form2542 KBhra-veba-election-form.pdf
HSA - Enrollment Form148 KBhsa-enrollment-form.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
Voluntary Additional AD&D Insurance Beneficiary Form215 KBvoluntary-additional-add-insurance-beneficiary-form.pdf
Voluntary Additional Life Insurance Beneficiary Form62 KBvoluntary-additional-life-insurance-beneficiary-form.pdf
Voya - EZ Enrollment Form486 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
Voya Beneficiary Maintenance Flyer402 KBvoya-online-beneficiary-maintenance-flyer.pdf

Contact us

Human Resources Department
Monday–Friday
8:00 a.m.–5:00 p.m.
555 Liberty ST SE RM 225
Salem OR 97301
Phone: