Payroll

Direct Deposit Form

W-4 Tax Withholding Form

 

Benefit Election

Benefit Election Form (including Life/AD&D beneficiary designation)

 

Health Care

Mail-Order Pharmacy Enrollment/Order Form (Elixir)

Medical/Dental Claim Form (also includes vision claims incurred through the end of 2023) 

Prescription Drug Claim Form (Elixir)

Spousal Health Care Affidavit

Dependent Coverage Form

Preauthorization Request/Approval Form

Health Plan Appeal Request Form/Claims Appeal Procedure

Formulary Exception Request Form

 

Flexible Spending Accounts

Accessing Your Navia Benefits Website

FSA Claim Form

FSA Direct Deposit Form

FSA Enrollment Form

Recurring Day Care Claim Form

 

Life Insurance

Life Insurance Calculator (xls)

Optional Life Insurance Worksheet (pdf)

Statement of Health Form - MetLife

MIB Statement of Health Form - MetLife

Portability Election Form - MetLife

Privacy Notice - MetLife

Conversion Form - MetLife

 

Family & Medical Leave (FMLA)

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

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

FMLA Request

 

Retirement

PSSP Info – Start Here

PSSP Account Access Information

PSSP Automatic Enrollment and Override Election Form

PSSP Beneficiary Designation

PSSP Hardship Withdrawal Application

PSSP In-Plan Roth Conversion Form

PSSP In-Service Withdrawal Application

PSSP Investment Options

PSSP Rollover Forms