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
2019 Flexible Spending Accounts Enrollment or Waiver Form200 KBflexible-spending-accounts-enrollment-or-waiver-form.pdf
2019 Health Savings Account (HSA) Enrollment Form180 KBhsa-enrollment-form.pdf
2020 Open Enrollment Flexible Spending Account (FSA) Enrollment Form137 KB2020-open-enrollment-flexible-spending-account-enrollment-form.pdf
2020 Open Enrollment Flexible Spending Limited Purpose Enrollment Form95 KB2020-open-enrollment-flexible-spending-limited-purpose-enrollment-form.pdf
2020 Open Enrollment Health Insurance Enrollment, Waiver, Change Form161 KB2020-open-enrollment-health-insurance-enrollment-change-form.pdf
2020 Open Enrollment Health Savings Account (HSA) Enrollment Form143 KB2020-open-enrollment-health-savings-account-enrollment-form.pdf
Additional AD&D Insurance Enrollment Beneficiary Form164 KBadditional-add-insurance-enrollment-beneficiary-form.pdf
Additional Life Insurance Enrollment Beneficiary Form69 KBadditional-life-insurance-enrollment-beneficiary-form.pdf
Birth Certificate Verification form201 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 Form124 KBcommute-expense-reimbursement-account-cera-claim-form.pdf
Commute Expense Reimbursement Account CERA Enrollment form100 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 Form240 KBebms-medical-vision-claim-form.pdf
Electronic Disclosure Form135 KBelectronic-disclosure-form.pdf
Employee Address or Emergency Contact Change form85 KBemployee-address-change-form.pdf
Employee or Dependent Name Change form158 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 Form159 KBhealth-hub-service-agreement-form.pdf
Health Insurance Coordination of Benefits137 KBhealth-insurance-coordination-of-benefits-form.pdf
Health Insurance Enrollment, Waiver, Change Form162 KBhealth-insurance-enrollment-form.pdf
Health Insurance Opt-Out Waiver Incentive Form137 KBhealth-insurance-opt-out-waiver-incentive-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 KBdeferred-comp-ez-enrollment-form.pdf
Voya - Final Paycheck Deferral Form97 KBvoya-final-paycheck-deferral-form.pdf
Voya - Holiday Cash Out Deferral Form100 KBvoya-holiday-cash-out-deferral-form.pdf
Voya Enrollment form85 KBdeferred-comp-long-enrollment-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