Human Resources and Employee Benefit Forms

Categories:

Jobs

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 Size	Type
Additional AD&D Insurance Enrollment Beneficiary Form	164 KB
Additional Life Insurance Enrollment Beneficiary Form	69 KB
Birth Certificate Verification form	201 KB
City Paid Life and AD&D Insurance Beneficiary Form	289 KB
Commute Expense Reimbursement Account CERA Claim Form	113 KB
Commute Expense Reimbursement Account CERA Enrollment form	92 KB
Covid Protected Leave Application	72 KB
Disabled Dependent Certification form	459 KB
Domestic Partner Affidavit form	89 KB
Domestic Partner Termination form	72 KB
EBMS - Medical and Vision Claim Form	240 KB
Electronic Disclosure Form	135 KB
Employee Address or Emergency Contact Change form	90 KB
Employee or Dependent Name Change form	158 KB
Employee Request for Accomodation Form - ADA	1240 KB
Flexible Spending Accounts (FSA) Enrollment or Waiver Form	144 KB
Flexible Spending Accounts Claim Form	55 KB
Flexible Spending Accounts Mid Year Change Form	118 KB
Health Care Provider - Serious (Family)	60 KB
Health Care Provider - Serious (Self)	143 KB
Health Hub Service Agreement Form	159 KB
Health Insurance Coordination of Benefits	137 KB
Health Insurance Enrollment, Waiver, Change Form	161 KB
Health Insurance Opt-Out Waiver Incentive Form	137 KB
Health Savings Account (HSA) Enrollment Form	144 KB
Incident Report Form	571 KB
Life and Long Term Disability Form	314 KB
Medical Provider Inquiry Form - ADA	1240 KB
Military Exigency Leave	61 KB
Military Family Leave	68 KB
Optum RX Mail Order Prescription Form	497 KB
Optum RX Member Reimbursement Form	101 KB
PERS IAP Beneficiary Form	802 KB
PERS Tier 1 or Tier 2 Beneficiary Form	805 KB
Protected Leave Application	117 KB
Release of Health Information	104 KB
Release to Return to Work	48 KB
Veteran Military Caregiving Leave	120 KB
Voya - EZ Enrollment Form	590 KB
Voya - Final Paycheck Deferral Form	97 KB
Voya - Holiday Cash Out Deferral Form	90 KB
Voya Enrollment form	85 KB
Wellness Committee Supervisor Approval Form	100 KB

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

Email: [email protected]

Phone:

503-588-6162Human Resources main line503-589-2085Carrie Wagner's direct line