Benefit Forms



For New Employees
Form Category Description Submit To
Health Coverage Enrollment/Status Change Medical/Prescription/Dental/Vision

Status change
Enroll in, waive, or declare status change for medical/prescription, dental, and vision coverages Your HR office
Optum Bank HSA Application HSA Open an HSA with Optum Bank (required if you want to receive State contributions) Your HR office
HSA Employee Payroll Deduction Authorization HSA Make employee contribution to HSA via payroll deductions Your HR office
Waiver of Medical/Prescription Coverage Medical/Prescription Waive State medical/prescription coverage Your HR office
Dual State-Employed Spouses Declaration Medical/Prescription/Dental/Vision Complete this form during health enrollment if both you and your spouse are State employees Your HR office
Domestic Partner Dependent Delaration Medical/Prescription/Dental/Vision Enroll a domestic partner in the State employee health plan Your HR office
Affidavit of Domestic Partnership Medical/Prescription/Dental/Vision Enroll a domestic partner in the State employee health plan Your HR office
2017 FSA Enrollment(Only for new hires or employees experiencing a qualifying status change) FSA Open an FSA for the 2017 plan year Your HR office
Employee Group Life Insurance Life insurance Waive basic life insurance or enroll in supplemental life insurance Your HR office
Legal Care Deduction Authorization Legal coverage Enroll in or cancel legal coverage Your HR office
RIPTA Payroll Deduction RIPTA transit passes Purchase RIPTA passes via payroll deductions Your HR office

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For Active Employees
Form Category Description Submit To
Health Coverage Enrollment/Status Change Medical/Prescription/Dental/Vision

Status change
Enroll in, waive, or declare status change for medical/prescription, dental, and vision coverages Your HR office
Optum Bank HSA Application HSA Open an HSA with Optum Bank (required if you want to receive State contributions) Your HR office
HSA Employee Payroll Deduction Authorization HSA Make employee contribution to HSA via payroll deductions Your HR office
Waiver of Medical/Prescription Coverage Medical/Prescription Waive State medical/prescription coverage Your HR office
Dual State-Employed Spouses Declaration Medical/Prescription/Dental/Vision Complete this form during health enrollment if both you and your spouse are State employees Your HR office
Domestic Partner Dependent Delaration Medical/Prescription/Dental/Vision Enroll a domestic partner in the State employee health plan Your HR office
Affidavit of Domestic Partnership Medical/Prescription/Dental/Vision Enroll a domestic partner in the State employee health plan Your HR office
UHC Out-of-Network Claim Form Medical Submit claims for out-of-network doctor visits UHC
CVS Caremark Mail Order Prescription Fill a 90-day maintenance prescription under the Maintenance Choice program CVS Caremark
CVS Caremark Rx Claim Prescription Obtain reimbursement for out-of-network prescription claims CVS Caremark
FSA Claim Form FSA Submit claims for FSA-eligible expenses Your HR office
Unforeseeable Emergency Withdrawal Request Deferred compensation Withdraw from your deferred compensation account if you are experiencing a qualifying unforeseeable emergency OEB
Distribution Election Form Deferred compensation Withdraw from, transfer, or rollover your deferred compensation account OEB
Age 50 Catch Up Request Deferred compensation Make a catch-up contribution if you are over age 50 before the close of the taxable year; cannot be combined with other catch up requests OEB
Regular Catch Up Request Deferred compensation Make a catch-up contribution if you are within three years of normal retirement age, not including the year of retirement; cannot be combined with other catch up requests OEB
Death Claim Form (obtain from provider) Deferred compensation For the beneficiary to submit claims if the plan participant is deceased OEB
Employee Group Life Insurance Life insurance Waive basic life insurance or enroll in supplemental life insurance Your HR office
Aetna Beneficiary Designation Life insurance Designate beneficiary for your life insurance policy Aetna
Legal Care Deduction Authorization Legal coverage Enroll in or cancel legal coverage Your HR office
RIPTA Payroll Deduction RIPTA transit passes Purchase RIPTA passes via payroll deductions Your HR office
Physician Screening Rewards for Wellness Indicate completion of your cholesteral, non-fasting glucose, and/or BMI screening UnitedHealthcare
Physician Blood Pressure Screening Rewards for Wellness Indicate completion of your blood pressure screening UnitedHealthcare
YMCA DPP Eligibility Worksheet Diabetes Prevention Program Determine whether you and your dependents quality to participate in the Diabetes Prevention Program For reference only; submission is not required
Seasonal Flu Consent Form 2016-2017 Flu Shot Document your seasonal flu shot N/A; complete this form when you obtain your flu shot

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For Retirees
Form Category Description Submit To
Pre-65 Retiree Health Coverage Election Pre-65 (non-Medicare-eligible) retiree health coverage Enroll in State-sponsored pre-65 retiree health coverage OEB
Retiree Health Coverage Cancellation Pre-65 (non-Medicare-eligible) retiree health coverage Cancel your State-sponsored pre-65 retiree health coverage OEB
Medicare Exchange Eligibility Post-65 (Medicare-eligible) retiree health coverage Complete this form if you are planning to purchase a Medicare Supplement (Medigap) policy, Medicare Advantage policy, and/or a Part D prescription drug plan through the State’s Medicare exchange vendor, or if you are already retired from State service and your spouse would also like to purchase a plan through the State’s vendor. OEB
Age 50 Catch Up Request Deferred compensation Make a catch-up contribution if you are over age 50 before the close of the taxable year; cannot be combined with other catch up requests Your HR office
Regular Catch Up Request Deferred compensation Make a catch-up contribution if you are within three years of normal retirement age, not including the year of retirement; cannot be combined with other catch up requests Your HR office
Death Claim Form (obtain from provider) Deferred compensation For the beneficiary to submit claims if the plan participant is deceased Plan provider
Basic Group Life Insurance Election (obtain form from ERSRI) Life insurance Maintain life insurance coverage when you retire from State service ERSRI

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