Benefits Forms

Medical Enrollment and Change Form:

• Medical Enrollment and Change Form (HR-124)

Flexible Spending Account (FSA) Enrollment Forms:

• Flexible Spending Account (FSA) Enrollment/Change Form (HR-135)

Health Plan Eligibility & Deduction Authorization for Both Spouse Employees Form:

• FCPS Health Plan Eligibility & Deduction Authorization for Both Spouse Employees Form (HR-134)

Disability Certification for Overage Dependent Forms:

• Aetna (dental coverage) 
  (Both forms must be completed and submitted to Aetna):
  • Request for Continuation of Coverage For Disabled Child
  • Disabled Child Attending Physician’s Statement
• Cigna Open Access Plus (medical coverage)
  (Both forms must be completed and submitted to Cigna): 
  • Cigna Handicapped Disabled Dependent - Family Form
  • Cigna Handicapped Disabled Dependent - Physician Form
• Kaiser Permanente (medical coverage)
  • Contact Kaiser Member Services at 301-468-6000

Retirement Forms are available at FCERS, ERFC, VRS.

• FCERS Retirement Plan E/Beneficiary Designation Form

403(b)

• Plan Enrollment

• 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).

457(b)

• Plan Enrollment

Hybrid 457

• Plan Enrollment