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State of Rhode Island

Rhode Island Office of Employee Benefits

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Benefit Forms

Affidavit of Eligibility For Children Under Age 26

Benefit Packet Overview

Civil Union Tax Dependent Form

Common Law Affidavit

Deferred Compensation Informational Letter

Deferred Compensation Age 50 Catch Up Request Form

Delta Dental Claim Form

Domestic Partner Affidavit

Domestic Partner Dependent Declaration Form

Flex Plan Dependent TASC Debit Card Request Form

Flex Plan Direct Deposit Form

Flex Plan FlexSystem Enrollment and Change Form

Flex Plan Unpaid Leave Form

Health Insurance Enrollment/Status Change Form

Legal Care Payroll Deduction Authorization

Life Insurance Form - Waive Coverage

Life Insurance Beneficiary Form

Medco by Mail Order Form

Medco Rx Claim Form

UnitedHealthcare Out-of-Network Claim Form

Waiver of Medical Coverage Form

Waiver of Pre-Tax Health Co-Share Form

For HR/Payroll Use Only

A-93 Health Insurance Direct Remittance Form

A-94 Life Direct Remittance Form

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