Benefits Forms
Information about Benefits Forms and Supporting Documentation
Medical, Dental, and Flexible Spending Account Forms
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
Disability and Leaves Forms
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:
- Request for an Unpaid Leave of Absence (LOA) Form (HR-136)
- Certification of Health Care Provider for Employee's Serious Health Condition to support an LOA Request (HR-180)
- Certification of Health Care Provider for Family Member's Serious Health Condition to support an LOA Request (HR-181)
Life Insurance 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)
Retirement and Supplemental Retirement Savings Plans Forms
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FCERS Retirement Plan E/Beneficiary Designation Form
FCERS Retirement Plan E/Beneficiary Designation Form
403(b)
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Transaction Routing Request Form
This form must accompany any contract exchange, rollover, distribution, or loan request paperwork provided by your 403(b) vendor.
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401k Financial Hardship Rules applicable to 403(b)
This document further explains the rules for withdrawing funds due to a financial hardship.
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403(b) Hardship Withdrawal Disclosure
This form certifies that you have incurred a financial hardship as defined by the Internal Revenue Service (IRS).