| 2020 Flexible Spending Accounts (FSA) Enrollment or Waiver form | Complete this form for enrollment or waiver in the flexible spending accounts for 2020 | 144 KB |
| 2020 Health Insurance Enrollment, Waiver, Change form | Complete this form to enroll or waive coverage of the City of Salem health insurance for 2020. | 162 KB |
| 2020 Health Insurance Opt-Out Waiver Incentive form | Complete this form to waive coverage on the City's health plans for 2020 because you have other qualifying health insurance. Documentation of enrollment in other qualifying coverage is required. 2020 AFSCME, PCEA, and Unrepresented employees only | 137 KB |
| 2020 Health Savings Account (HSA) Enrollment form | Complete this form if you elect to enroll in the HDHP medical plan, or qualify for the Opt-Out Waiver Incentive and are HSA eligible per IRS rules for 2020 enrollment | 144 KB |
| 2021 Flexible Spending Accounts (FSA) Enrollment or Waiver form | Complete this form for enrollment or waiver in the flexible spending accounts for 2021 | 176 KB |
| 2021 Health Insurance Enrollment, Waiver, Change form | Complete this form to enroll or waive coverage of the City of Salem health insurance for 2021. | 165 KB |
| 2021 Health Insurance Opt-Out Waiver Incentive form | Complete this form to waive coverage on the City's health plans for 2021 because you have other qualifying health insurance. Documentation of enrollment in other qualifying coverage is required. 2021 AFSCME, PCEA, SPEU, and Unrepresented employees only. | 158 KB |
| 2021 Health Savings Account (HSA) Enrollment form | Complete this form if you elect to enroll in the HDHP medical plan, or qualify for the Opt-Out Waiver Incentive and are HSA eligible per IRS rules for 2021 enrollment | 150 KB |
| Electronic Disclosure form | Complete this form to acknowledge the City's intent to deliver plan documents and notices electronically. | 135 KB |
| Health Hub Service Agreement form | Complete this form to agree to the terms of use for the Health Hub employee health clinic. | 159 KB |
| Health Insurance Coordination of Benefits form | Complete this form to report that you or your dependents have other health insurance coverage. | 137 KB |
| Standard Life, ADD, and LTD Enrollment Beneficiary form | Complete this form to designate or update your beneficiary on the City provided Life Insurance and AD&D policy. | 314 KB |
