Employers

Employer Forms

Employee Change/Termination Form (PDF - 87.5 KB)
This form is used when there is a change in an employee's status. Examples of this are: Class or Position, Beneficiary Change, Name Change/Conversion, Rehire(enrollment may be required), Leave of Absence, Salary Termination
Employer Statement Form (PDF - 57.7 KB)
This form is used to verify information for disability claims.
Flexible Spending Account Change of Status Form (PDF - 45.6 KB)
This form is used to add a dependent or revise an employee's pledge amount. Do not use this form to terminate FSA benefits. Use the FSA Termination Form for that purpose.
Flexible Spending Account Employee Application (PDF - 82.7 KB)
This form is used to enroll employees for Flexible Spending Account benefits. Important note to employers with option for direct deposit: Contact the Policy Administration Department for the correct enrollment form.
Flexible Spending Account Termination Form (PDF - 47.3 KB)
This form is used to terminate an employee's Flexible Spending Account.
HRA - Health Reimbursement Arrangement Employer Application (PDF - 100.7 KB)
This form is used to enroll a new HRA Plan for an employer. This form is not to be used for enrolling employees in an existing HRA plan.
MERP - Medical Expense Reimbursement Plan Employer Application (PDF - 73.2 KB)
This form is used to enroll a new Medical Expense Reimbursement Plan for an employer. This form is not to be used for enrolling employees in an existing MERP plan.
Premium Only Plan / Flexible Spending Account Employer Application (PDF - 83.4 KB)
This form is used to enroll a new Premium Only Plan and/or Flexible Spending Account plan for an employer. This form is not to be used for enrolling employees in an existing Flexible Spending Account plan.
Sample EOB (PDF - 65.6 KB)
Explanation of Benefits (EOB) sample
Section 125 213d Eligible Expenses (PDF - 152.8 KB)
Eligible expenses allowed under 213D
Self-Funded Group Enrollment Form (PDF - 76.7 KB)
This form is used to enroll employees and dependents for health, dental, vision, life or STD coverage.