Benefits Forms

Beneficiary

• Basic Group Life Insurance, Optional Life Insurance, and VRS Retirement

Claims

• Anthem Claim Form
• Flexible Reimbursement Account Claim Form
• Blue View Vision Out-of-Network Claim Form

Deferred Compensation

• Deferred Compensation Plan (457) Enrollment Form
• Deferred Compensation Plan Enrollment Form for Wage Employees
• Deferred Compensation Plan Payroll Authorization Form – One-Time Deferral
• Salary Reduction Agreement

Health / Life

• July 1, 2019-June 30, 2020 Health Insurance Premium Rates
• Health Insurance Appeal Form
• Optional Group Life Insurance Request for Change
• Health Benefits Enrollment Form

Workers’ Compensation