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Bereavement
Hearing Co-Pay Reimbursement
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Survivor’s Benefit
Identity Theft & Fraud Protection
Civil Service Consulting
Health Insurance Assistance
Legal
Legal Benefits Schedule
Financial Planning
Discounts
Auto & Home Insurance (Farmers)
Pet Insurance (MetLife)
Tax Preparation Reimbursement
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“No-Cost” Basic Retirees
“Self-Pay” Enhanced Retirees
Voucher Requests
Forms
1095 Request Form
All Other Forms
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Beneficiary (4)
Claims (8)
COBRA (2)
Domestic Partner (3)
Misc (3)
Retiree Self-Pay (Sperp) (2)
Statement of Dependence (2)
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Beneficiary
Beneficiary Forms - Active
69.9 KB
Beneficiary Forms - Retired Member
75.0 KB
Death Notification Form
84.1 KB
MetLife Voluntary Life Beneficiary Form
953.7 KB
Claims
ADA Dental Claim Form
214.9 KB
Health Insurance Assistance Claim Form for 2023
156.7 KB
Health Insurance Assistance Claim Form for 2024
156.9 KB
Metlife Dental Claim Form 1-1-25
4.4 MB
Metlife Short Term Disability Claim Form
423.7 KB
Prescription Claim Form
209.7 KB
Specialist Claim Form for 2023
112.8 KB
Specialist Claim Form for 2024
111.3 KB
COBRA
COBRA Coverage Application
239.5 KB
COBRA Coverage Pre-Payment Application
104.9 KB
Domestic Partner
Domestic Partner FULL Application
334.5 KB
Domestic Partner Renewal Affidavit
104.8 KB
Domestic Partner Termination Application
83.5 KB
Misc
Change of Address Form
256.0 KB
Check Replacement Affidavit
76.0 KB
Opt-Out, Opt-Back-In Form 1-6-25
93.5 KB
Retiree Self-Pay (Sperp)
SPERP Enrollment Form (2025)
165.7 KB
SPERP Enrollment Packet (2025-26 Rates)
404.6 KB
Statement of Dependence
Statement of Dependence Application - Custodial 1-6-25
181.7 KB
Statement of Dependence Application - Medical
228.2 KB
