Home Benefit Forms

Benefit Forms

STATE HEALTH PLAN

Enrollment Form

Medical Claim Form

Prescription Reimbursement Claim Form (Medco as of 4/1/2005)

Authorization Form

Status Change Form

Prior Health Coverage Form

TRICARE Enrollment Form

TRICARE Other Health Insurance Form (OHI)

NC FLEX

Status Change Form

Spending Account Claim Form

FSA Convenience Card Claim Form

FSA Convenience Card Enrollment Form

FSA Convenience Card Dependent Card Request Form

Dental Claim Form

Vision Claim Form

Supplemental Medical Claim Form

Unum Beneficiary Form

HIPAA Authorization Form

Cancer Claim Form

Cancer Conversion Form

Term Life EOI Form

Term Life Death Claim Form

Term Life Beneficiary Form

Term Life Continuation Form

DISABILITY PLANS

Liberty Mutual Enrollment Form

Liberty Mutual Statement of Health

Liberty Mutual Termination Form

Liberty Mutual Change Form

Standard Insurance Co. Enrollment Form

Standard Insurance Co. Statement of Health

For claim forms, please contact the Benefits office 515-2151

WORKERS COMPENSATION (For Supervisor's use only)

First Report of Injury

NCIC Form 19

Medical Authorization and Attending Physician's Report

Employee Statement & Leave Options

For additional information about workers compensation please click here

LIFE INSURANCE

MetLife Enrollment Form

MetLife Statement of Health Form

MetLife Beneficiary Form

RETIREMENT

TSERS/LEORS

TSERS and LEORS Enrollment Form

Change of Beneficiary/Address Form

Request a Retirement Calculation

Refund of Retirement Contributions (upon termination of employment)

ORP Enrollment Form

ORP Forms

TSERS/LEORS Required Forms for Retirement:

Application for Retirement

Direct Deposit Authorization Form

Tax Withholding Form

State Health Plan Retiree Enrollment Form

Additional TSERS Forms

Social Security form for Medicare if age 65 or older

ORP Required Forms for Retirement:

State Health Plan Retiree Enrollment Form

Social Security form for Medicare if age 65 or older

SUPPLEMENTAL RETIREMENT

403(b) Salary Reduction Agreement

457 Salary Reduction Agreement

401(k) Enrollment Form

401(k) Change Form

Additonal Forms

Prepaid Legal Plan (Hyatt Legal)

Faculty/Staff Tuition Waiver Form

Forms are not available electronically for the following plans (please contact the Benefits office directly 515-2151.):

College Savings Plan

Savings Bonds

Voluntary Personal Liability Insurance