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Forms

Payroll

Direct Deposit Form

W-4 Tax Withholding Form

 

Health Care

Health Plan Appeal Request Form

HIPAA Privacy Authorization Form

Mail-Order Pharmacy Enrollment/Order Form (EnvisionMail)

Medical/Dental Claim Form

Prescription Drug Claim Form (Envision/Rx Options)

Spousal Health Care Affidavit

Vision Claim Form

 

Flexible Spending Accounts

Accessing Your Navia Benefits Website

FSA Claim Form

FSA Direct Deposit Form

FSA Enrollment Form (also known as Salary Redirection Agreement [SRA])

 

Life Insurance

Life Insurance Calculator (xls)

Optional Life Insurance Worksheet (pdf)

Statement of Health Form - MetLife

 

Family & Medical Leave (FMLA)

FMLA Certification for Serious Injury or Illness of Covered Servicemember - for Military Family Leave

FMLA Certification of Health Care Provider for Employee's Serious Health Condition

FMLA Certification of Health Care Provider for Family Member's Serious Health Condition

FMLA Certification of Qualifying Exigenzy for Military Family Leave

FMLA Request

 

Retirement

PSSP Account Access Information

PSSP Automatic Enrollment and Override Election Form

PSSP Beneficiary Designation

PSSP Hardship Withdrawal Application

PSSP In-Service Withdrawal Application

PSSP Rollover Forms