Benefit Forms

 

Benefit Forms:

• Status Change

• Pre-Tax Payment Election Form

Dental Care:

• Delta Dental Enrollment/Change Form

Flexible Spending:

• 2012 FSA Benny Debit Card / Direct Deposit Authorization Form

• 2012 FSA Enrollment Form

Health Care:

• Southern Health Enrollment/Change Form

• Medco Mail Order RX Form

Long Term Income Protection (LTIP):

• LTIP Enrollment Form

• LTIP Claim Form

• LTIP Evidence of Insurability Form

Payroll Forms:

• Direct Deposit Form

• Federal Tax Form

• State Tax Form

Short Term Income Protection (STIP):

• Aetna Evidence of Insurability Form (EOI)

• STIP Enrollment Form

Privacy Notice: Information requested on these forms is necessary to enroll in the benefit selected; to ensure compliance with federal Equal Employment Opportunity laws; to meet reporting requirements for state and federal laws; for retirement and insurance purposes; and/or for statistical reports. To the extent permitted by law, this information will be kept confidential by the County and its benefit providers.