Forms

2019 Plan Year Open Enrollment

• Active Employee Open Enrollment for 2019 Oct. 1 - Oct. 31, 2018
• All Self-Pay Participants Open Enrollment Oct. 1 to Oct. 21, 2018
• All Self-Pay Participants Open Enrollment Correction
• FSA Open Enrollment Oct. 1 - Oct. 31, 2018

2018 Enrollment

• New Hire Enrollment Form
• Commuter Account
• Flexible Spending Account
• Retiree
• Self-pay
• Long-term Care Insurance

Covering Others

• Affidavit of Dependency
• Affidavit of Domestic Partnership
• Grandchild by Affidavit
• Domestic Partner for Tax Status

Midyear Change

• Midyear Change
• Flexible Spending Account
• Healthcare FSA Prepay Request
• Qualified Reservist Distribution Request

Life & Disability Insurance (The Standard/PEBB)

• Transfer Premium Payment

Long Term Care Insurance (Unum/PEBB)

• UNUM long term care insurance coverage

Other Forms

• Appeal
• Beneficiary Designation
• CDL Exam Eligibility Voucher
• 2019 HEM Exemption Request