information for the community

For New Hires and Family Status Changes Outside of Open Enrollment,
Click on the form needed, complete, print and send to Employee Benefits.

**All requests for changes to benefits must be received within 31 calendar days of the qualifying event. In the event that the 31st day falls on a weekend or holiday, (including closed business days), requests must be received on the last working day prior to your 31st day.

***TSA enrollment/changes can be made at anytime throughout the year.

Cancellation Form-Life and Disability To cancel benefits that are not on the Cafeteria Plan (pre-taxed)

 

When to use
Whole Life When to use
Cancer Enrollment/Cancellation Form New Enrollment, change in coverage, or cancellations Change Requests Personal Info., Cancellation, Beneficiary, or coverage changes
Wellness Claim Form Filing a wellness claim for exam performed

Whole Life Insurance Application

When applying for Whole Life Insurance
Cancer Change Form Changes to existing Cancer coverage    
Claim Form Filing cancer/specified disease/ICU/Heart/Stroke Claims    

When to use
When to use

Sick Leave Bank Enrollment Form

Enrollment form to join the Sick Leave Bank.

Dental Enrollment/Change Form **For New Hires and Family Status Changes Only

New enrollees, add, cancel dependents.

Sick Leave Bank Physician's Statement

Complete page 1, Application for days must accompany Physician's statement.

Cafeteria Plan Election Change **For Family Status Changes only Complete this form to make changes to your benefit selections already on the Cafeteria plan when you experience a family status change outside of the Open Enrollment period.
Sick Leave Bank Application - Sick Days Complete page 1, Physicians Statement must accompany Sick Leave Bank Application for days.

 

 


When to use

When to use

Application for Coverage.

New Employee Enrollment form (within first 60 days of employment).

Hospital Indemnity Claim Form

$250 per day reimbursement for inpatient hospital confinement.

Disability Claim Form
For employees who wish to make a benefit claim    

Incentive Program

When to use

Life/Survivor Benefits

When to use

MetLife 401(a) change form This form is to be used by current participants only. For personal information changes.

Life- Enrollment Form

Life Insurance enrollment form. For Family Status Changes.
    Dependent and Coverage changes
MetLife Beneficiary Designation-401(a) Beneficiary changes for participants

Designation of Beneficiary - TRS

Updates TRS beneficiary only.

MetLife Annuity Distribution Form To claim 401(a) district deposits

Employer Paid Group Term Life Insurance Booklet

For all TRS eligible employees.

    Guardian Basic Term Life Insurance

Required when outside new hire enrollment and related Family Status Changes



Medical When to use Section 125 (cafeteria/FSA) When to use
Health Insurance Enrollment Form New Enrollment or Change in Health Coverage due to a qualified Family Status Change.

Cafeteria Plan Election Change

Complete this form to make changes to your benefit selections when you experience a family status change outside of the Open Enrollment period.

Medical Reimbursement Claim Form Members with medical benefits through BCBS can use this form to file medical claims for reimbursement.    

Cafeteria Plan Election Change

Complete this form to make changes to your benefit selections when you experience a family status change outside of the Open Enrollment period.

Flexible Spending Change Forms

For Family Status Changes to your FSA account.

Mail Order Prescription Form

Order your prescriptions through our mail order program

Flexible Spending Enrollment Form For new enrollments.
Prescription Reimbursement Claim Form Members with pharmacy benefits through BC/BS can use this form to file pharmacy claims for reimbursement.
This form is to be used for those participants who have not received a membership card and must pay out of pocket.
   
Tax Sheltered Accounts When to use Vision Plan When to use

Tax Sheltered Accounts (403b)

Salary Reduction Agreement & Disclaimer Statement - 403b, Tax Sheltered Annuity.

Enrollment Form
**For New Hires and Family Status Changes only.
New Enrollment or Change in Coverage. Complete the Cafeteria Plan Election Change Form if you elect to have your premium on the Cafeteria Plan.
MetLife 457(b) change form This form is to be used by current participants only. For personal information changes.

Cafeteria Plan Election Change **For Family Status Changes only

Complete this form to make changes to your benefit selections already on the Cafeteria plan when you experience a family status change outside of the Open Enrollment period.

MetLife 457(b) distribution form This form is to be used by current participants only.

 

 

MetLife 457(b) beneficiary change form Beneficiary changes for participants