Forms

Domestic Partner Affidavit (for insurance related purposes, as well as use of sick leave and humanitarian leave)

Domestic Partner Affidavit (for non-insurance related purposes, only the use of sick leave and humanitarian leave)

Domestic Partner Termination Form

HSA Mistaken Distribution Form

HSA Payroll Deduction Authorization Form - 2012

Insurance Coverage Agreement While on Leave Form

Life Insurance Enrollment Form

Life Insurance Evidence of Insurability (EOI) Form

Medical and Dental Insurance Enrollment Form

Section 125 - Flexible Spending Account - Claim Form

Section 125 - Flexible Spending Account - Change in Status Form

Section 132 - Pre-Tax Parking and Transit - Enrollment Form

Section 132 - Pre-Tax Parking and Transit - Claim Form

Section 125 and 132 - Direct Deposit Form

Authorization to Release Information for Management Referrals

Confirmation of Attendance for Management Referrals

 

UnitedHealthcare

UnitedHealthcare Claim Form

PO Box 30555
Salt Lake City, UT 84130

UnitedHealthcare RX Reimbursement Claim Form - Medco RX

Medco Health Solutions
P.O. Box 14711
Lexington, KY 40512

Pima County Dental Claim Form