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. Find links to detailed information about benefits for your specific employee group from the jobs page.

Title (with link to item)File SizeType
2022 Open Enrollment Flexible Spending Account (FSA) Enrollment form170 KBopen-enrollment-flexible-spending-accounts-enrollment-form.pdfopen-enrollment-flexible-spending-accounts-enrollment-form.pdf Checked Out To: Carrie Wagner
2022 Open Enrollment Flexible Spending Account (FSA) Limited Purpose Enrollment form112 KBopen-enrollment-flexible-spending-limited-purpose-enrollment-form.pdfopen-enrollment-flexible-spending-limited-purpose-enrollment-form.pdf Checked Out To: Carrie Wagner
2022 Open Enrollment Health Insurance Opt-Out Waiver Incentive form154 KBopen-enrollment-health-insurance-opt-out-waiver-incentive-form.pdfopen-enrollment-health-insurance-opt-out-waiver-incentive-form.pdf Checked Out To: Carrie Wagner
2022 Open Enrollment Health Savings Account (HSA) Enrollment form147 KBopen-enrollment-health-savings-account-enrollment-form.pdfopen-enrollment-health-savings-account-enrollment-form.pdf Checked Out To: Carrie Wagner
ADA Employee Request for Accommodation form1240 KBhr-034-employee-request-for-accommodation-form-ada.pdf
ADA Medical Provider Inquiry form1240 KBhr-035-medical-provider-inquiry-form-ada.pdf
Birth Certificate Verification form201 KBbirth-certificate-verification-form.pdf
Commute Expense Reimbursement Account (CERA) Claim form108 KBcommute-expense-reimbursement-account-cera-claim-form.pdf
Commute Expense Reimbursement Account (CERA) Enrollment form90 KBcommute-expense-reimbursement-account-cera-enrollment-form.pdf
Covid Protected Leave Application72 KBhr-017-covid-protected-leave-application.pdf
Disabled Dependent Health Insurance Certification form459 KBdisabled-dependent-certification-form.pdf
Domestic Partner Health Insurance Affidavit form89 KBdomestic-partner-affidavit-form.pdf
Domestic Partner Health Insurance 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 form86 KBemployee-address-change-form.pdf
Employee or Dependent Name Change form92 KBhr-063-employee-or-dependent-name-change-form.pdf
Flexible Spending Accounts (FSA) Enrollment or Waiver form175 KBflexible-spending-accounts-enrollment-or-waiver-form.pdf
Flexible Spending Accounts (FSA) Mid Year Election Change form101 KBflexible-spending-accounts-mid-year-change-form.pdf
Flexible Spending Accounts (FSA) Reimbursement Claim form62 KBflexible-spending-accounts-claim-form.pdf
Hartford Additional AD&D Insurance Enrollment Beneficiary form164 KBadditional-add-insurance-enrollment-beneficiary-form.pdf
Health Hub Service Agreement form159 KBhealth-hub-service-agreement-form.pdf
Health Insurance Coordination of Benefits form137 KBhealth-insurance-coordination-of-benefits-form.pdf
Health Insurance Enrollment, Waiver, Change form165 KBhealth-insurance-enrollment-form.pdf
Health Insurance Opt-Out Waiver Incentive form154 KBhealth-insurance-opt-out-waiver-incentive-form.pdf
Health Savings Account (HSA) Enrollment form150 KBhealth-savings-account-enrollment-form.pdf
Incident Report form571 KBincident-report-form.pdf
Long Term Disability (LTD) Benefit Claim Packet250 KBltd-benefit-claim-packet.pdf
Military Exigency Leave Application61 KBhr-021-protected-leave-military-extgency-leave.pdf
Military Family Leave Application68 KBhr-022-protected-leave-serious-military-family.pdf
Military Veteran Caregiving Leave Application120 KBhr-023-protected-leave-veteran-care.pdf
Optum RX Member Reimbursement form101 KBoptum-rx-member-reimbursement-form.pdf
PERS IAP Beneficiary form802 KBpers-iap-beneficiary-form.pdf
PERS Tier 1 or Tier 2 Beneficiary form805 KBpers-tier-1-or-tier-2-beneficiary-form.pdf
Protected Leave Application117 KBhr-017-protected-leave-application.pdf
Protected Leave Health Care Provider Certification form - Serious (Family)60 KBhr-020-protected-leave-family-serious-cert.pdf
Protected Leave Health Care Provider Certification form - Serious (Self)143 KBhr-019-protected-leave-health-care-provider-serious-self.pdf
Protected Leave Release of Health Information form104 KBhr-018-protected-leave-release-of-health-information.pdf
Protected Leave Release to Return to Work form48 KBhr-026-release-to-return-to-work.pdf
Standard Additional Life Insurance Enrollment Beneficiary form69 KBadditional-life-insurance-enrollment-beneficiary-form.pdf
Standard Life, ADD, and LTD Enrollment Beneficiary form314 KBlife-and-long-term-disability-form.pdf
Voya Deferred Compensation Enrollment form with investment options85 KBdeferred-comp-long-enrollment-form.pdf
Voya Deferred Compensation EZ Enrollment form590 KBdeferred-comp-ez-enrollment-form.pdf
Voya Deferred Compensation Final Paycheck Deferral form97 KBvoya-final-paycheck-deferral-form.pdf
Voya Deferred Compensation Holiday Cash Out Deferral form87 KBvoya-holiday-cash-out-deferral-form.pdf
Welldyne At-Home COVID Test Reimbursement claim form64 KBwelldyne-rx-athome-covid-test-reimbursement-form.pdf
Welldyne Mail Order Pharmacy Registration form162 KBwelldyne-mail-order-pharmacy-registration-form.pdf
Welldyne Member Reimbursement Claim form180 KBwelldyne-member-reimbursement-form.pdf
Wellness Committee Supervisor Approval form100 KBwellness-committee-supervisor-approval-form.pdf

Contact us

Michele BennettHuman Resources ManagerCarrie WagnerHuman Resources Department
Monday–Friday
8:00 a.m.–5:00 p.m.
295 Church ST SE Suite 210
Salem OR 97301
Phone: 
503-588-6162Human Resources main line503-589-2085Carrie Wagner's direct line