Benefits Forms
Information about Benefits Forms and Supporting Documentation
This is a comprehensive collection of forms for healthcare, retirement, disability, or other employee benefits.
Medical Enrollment and Change Form:
Flexible Spending Account (FSA) Enrollment Forms:
Health Plan Eligibility & Deduction Authorization for Both Spouse Employees Form:
Disability Certification for Overage Dependent Forms:
- Aetna (dental coverage)
(Both forms must be completed and submitted to Aetna): - Cigna Open Access Plus (medical coverage)
(Both forms must be completed and submitted to Cigna): - Kaiser Permanente (medical coverage)
- Contact Kaiser Member Services at 301-468-6000
Family Medical Leave (FMLA) Forms:
- Request for a Foreseeable Family Medical Leave (HR-126)
- Certification of Health Care Provider for Employee's Serious Health Condition to support an FMLA Request (HR-146)
- Certification of Health Care Provider for Family Member's Serious Health Condition to support an FMLA Request (HR-147)
- Certification for Serious Injury or Illness of Covered Servicemember--for Military Family Leave (HR-148)
- Certification of Qualifying Exigency for Military Family Leave (HR-149)
Leave of Absence (LOA) Forms:
FCERS Life Insurance: MetLife for members of FCERS
- Optional Employee & Dependent Life Insurance Election and Change Form (HR-142)
- Metlife Statement of Health (SOH)
- Metlife Optional Employee & Dependent Life Insurance Cost of Coverage Worksheet
- Notice of Group Life Insurance Conversion Privilege Form
VRS Life Insurance: Securian Financial for members of VRS
- Enrollment Application for VRS Optional Group Life Insurance (VRS-39)
- Group Life Evidence of Insurability (VRS-32)
- Designation of Beneficiary: VRS members and retirees can review and update beneficiaries online through their secure myVRS account.
- Life Insurance Conversion Form (VRS-35)
403(b)
- Transaction Routing Request Form: This form must accompany any contract exchange, rollover, distribution, or loan request paperwork provided by your 403(b) vendor.
- 401k Financial Hardship Rules applicable to 403(b): This document further explains the rules for withdrawing funds due to a financial hardship.
- 403(b) Hardship Withdrawal Disclosure: This form certifies that you have incurred a financial hardship as defined by the Internal Revenue Service (IRS).
A Complete Benefits Contacts List for FCPS Employees and Retirees
Here you will find a complete contact list for FCPS benefits, including websites, phone numbers, and email addresses.
Dependent Eligibility Chart
Here you will find the documentation required by FCPS in order to add or remove a dependent from your health insurance.
Qualifying Life Events
Here you will find information about how to make changes to your benefits due to a major qualifying life event.