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Benefits Forms

Although many changes can be done through Employee Self-Service (ESS), eliminating the need to complete and submit a form, some documentation may still be required.  Please make sure to submit all required documentation to the Benefits office within the established timelines.  Otherwise, you will need to wait until the next open enrollment period to make the change.  You can submit forms in person, through interoffice mail, or by scanning the form and submitting it via email.

 

Commonly Used Forms

Dependent Eligibility Verification form

Qualifying Life Event Information


Domestic Partner Enrollment Information
Affidavit of Domestic Partnership- Contact the Benefit Office

Information on Domestic Partnership Imputed Income Rates
Affidavit of Domestic Partnership Termination

Deferred Compensation

ICMA-RC Enrollment Packet - Available to all City employees
ICMA-RC Name Change Form
ICMA-RC Beneficiary Change Form
ICMA-RC Deferral Change Form
ICMA-RC Loan Procedures- Effective April 1, 2016
ICMA-RC Emergency Withdrawal Packet
ICMA-RC Catch-Up Provision Packet
ICMA-RC Direct Rollover/Transfer
Co-Provider Transfer to ICMA-RC (From Nationwide Only)
Rollover out of ICMA-RC

Nationwide Enrollment Packet - Available to Local 31 employees only
Nationwide Deferral Change Form
Nationwide Name-Address-Beneficiary Change Form
Nationwide Loan Application
Nationwide Catch-Up Form
Nationwide Outgoing Transfer Request
Nationwide Incoming Assets Form

Flexible Spending Forms

 (Submit Directly to Trusteed Plan Services)

FSA Authorization for Direct Deposit

FSA Reimbursement Request

FSA Letter of Medical Necessity

Life and Disability Forms

 (Submit to Human Resources Benefits Office)
Standard Long Term Disability Claim Form - Contact Benefits for Information
Standard Insurance Medical History Statement - Life Insurance or LTD

Short Term Disability

 (Submit to Human Resources Benefits Office)
MetLife Statement of Health Form - Optional Short Term Disability
MetLife Short Term Disability Claim Form - Contact Benefits for Information

Regence and Group Health

Regence Claim Reimbursement Form
Regence Mail Order Pharmacy Flyer
Regence Mail Order Pharmacy Registration Form
Regence Mail Order Pharmacy Registration Instructions
Regence Specialty Pharmacy Flyer

Group Health Mail Order Prescription Brochure
Group Health Mail Order New Prescription Form
Group Health Mail Order Prescription Transfer Refill Form
Group Health Mail Order Prescription Refill Form

Retirement Beneficiary

Retirement Beneficiary Designation Form - City Retirement (TERS)
Police/Fire Retirement Beneficiary Designation Form - State of Washington (DRS)
Railroad Retirement Board - Tacoma Rail Only

 

Contact Us

(253) 573-2345
email