Benefits Forms

Information about Benefits Forms and Supporting Documentation

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):
- 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

Family Medical Leave (FMLA) Forms:

Leave of Absence (LOA) Forms:

FCERS Life Insurance: MetLife for members of FCERS

VRS Life Insurance: Securian Financial for members of VRS

FCERS Retirement Plan E/Beneficiary Designation Form
FCERS Retirement Plan E/Beneficiary Designation Form

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).