Forms

General

• Census Data
• Dependent Affidavit Form
• Address Change Form

Death

• Death Benefit Beneficiary Form
• Claimant Statement Form – Death Benefit

Disability

• Disability Form Explanation
• Short Term Weekly Disability Form
• Notice Regarding Disability Provision – Posting of Hours
• Authorization Agreement for Automatic Deposits (ACH)

H&W

• PIBF Fund Claim Form
• Accident Information Request Form
• Reimbursement Agreement
• Coordination of Benefits Form
• Release of Medical Information Form
• Sav-Rx Covid Reimbursement Form
  
• Appointment for Authorized Representative Form (For Appeal Procedure)
• Retiree Health Insurance Premium Authorization for Automatic Deduction
• Refusal and Waiver of Coverage (Opt-Out) – (available one time only)
• Revocation of Refusal and Waiver of Coverage (Opt-In) – (available one time only)

COBRA

• Authorization Agreement for Automatic Banking Withdrawal (ACH)

HRA

• Health Reimbursement Arrangement (HRA) Form Instructions
• HRA Claim Form
• HRA Authorization Agreement for Automatic Deposits (ACH)

Pension

• Retiree Health Insurance Premium Authorization Agreement for Automatic Deduction
• Tax Withholding Form
• Authorization Agreement for Automatic Deposits (ACH)

401(k)

• 401(k) Distribution Form (Processing may take up to 14-20 business days upon receipt of a completed form.)
• 401(k) Enrollment Form (Part 1 of 2)
• 401(k) Enrollment Form (Part 2 of 2)
• 401(k) Beneficiary Distribution Form
• Investment Election Form

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