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​2015 Enrollment for Members Newly Eligible Beginning Nov. 1, 2014

​New Employee beginning Nov.1, 2014

New COBRA Member beginning Nov. 1, 2014

New Retiree Member beginning Nov. 1, 2014

New Self-pay Member beginning Nov. 1, 2014


Open Enrollment Corrections

Employee Core and Optional

Flexible Spending Accounts

State Flexible Spending Accounts -(available ONLY to same-sex individuals with Registered Certificate of Domestic Partnership)

Commuter Accounts




​2014 Enrollment

Employee Core and Optional Benefits Enrollment
​Employee Flexible Spending Accounts Enrollment
Oregon Flexible Spending Accounts (available ONLY to same-sex individuals with Registered Certificate of Domestic Partnership)
Long Term Care Plan
Retiree Enrollment​
Self-Pay Participants Enrollment
Covering Others
Affidavit of Dependency
Affidavit of Domestic Partners
Grandchild by Affidavit
Domestic Partner for Tax Status
Domestic Partnership Termination
Midyear Change
Midyear Change
Midyear Tobacco-use Change
Flexible Spending Account
Healthcare FSA Prepay Request
Qualified Reservist Distribution Request
Life & Disability Insurance
Transfer Premium Payment
Disability Insurance Claims Packet (pdf)
Life Insurance Claims Packet (pdf)
Medical History Statement (pdf)
Medical History Statement Online
Optional Life Insurance Portability (pdf)
Retiree Life Conversion Packet (pdf)
Retiree Life Insurance Application (pdf)
Retiree Life Insurance Termination
MEDEX Travel Assist Program
Long Term Care Insurance
UNUM long term care insurance coverage
Long Term Care Continuation Form
Transfer Premium Payment
Other Forms
Beneficiary Designation
CDL Exam Eligibility Voucher
Flexible Spending Account Claims
VSP Reimbursement
Kaiser Health Assessment Exemption
​Providence Health Assessment Exemption
Can't find it?
View DAS' master forms page