Benefits Information

• AD&D Certificate of Insurance
• AD&D Claim Form
• AD&D Election Form
• AD&D Plan Book
• AD&D Rate Table
• AD&D Conversion Notice & Form
• AD&D Conversion Form Instructions
• Travel Assistance Program Guide
• AD&D Beneficiary Change Form

• Affidavit of Marriage/Domestic Partnership
  Affidavit used when you marry or form domestic partnership. Signed by the employee as well as spouse or partner.
• Statement of Marriage/Domestic Partnership Termination
  Form used when you divorce or terminate domestic partnership. Signed by employee only, but copy must be given to ex-spouse or domestic partner.

• Health Care Benefit Change Forms
  Form used to make changes to medical insurance and/or dependent eligibility.
• Add Benefits/Dependents | Remove Benefits/Dependents

• Deferred Compensation Plan Document
• Investment Policy
• Leave Cash-Out Authorization - Most
  This form applies to retiring with Most Employee Benefits employees whose group did not accept or vote for an HRA VEBA plan.
• Leave Cash-Out Authorization - SPOG and SPMA
  This form applies to retiring SPOG and SMPA employees.
• Deferred Compensation Unforeseeable Emergency Form
• Application and instructions for requesting unforseeable emergency withdrawal.
• Deferred Compensation Withdrawal Form
  Application for requesting an in-service withdrawal.
• Retired PSO Distribution Form
• Distribution for Payment of Qualified Health and Long-Term Care Insurance Premiums.
• Loan Repayment Change Form
  City of Seattle Voluntary Deferred Compensation Plan Loan Repayment Change Form

• FML Request
• FML Designation
• FML Notification
• Health Certification, Employee
• Health Certification, Family Member
• FML Military Exigency Certification
• FML Covered Service member Certification

• 2016 FSA Plan Guide
  

• FSA Reimbursements for Claims Only
•   Claim Reimbursement Form
  Form used to submit reimbursement request for eligible health and dependent care expenses.
• FSA Change Form
  Make allowable changes to current address, status or contributions for health and/or dependent care.
•  Benefits Card/Direct Deposit Request Form
  Form to authorize reimbursements to be deposited directly into your bank account and/or request for pre-paid Benefits Card to pay for qualified health care expenses up front.

• Group Term Life Insurance Election Form
  To enroll, terminate or make changes to Group Term Life Insurance.
• Group Term Life Beneficiary Change Form
  Beneficiary change form.
• Group Term Life Insurance Waiver
• Group Term Life Insurance Conversion Form
• Evidence of Insurability Form
• Evidence of Insurability Online Form
• Accelerated Death Benefit Claim Form
• GTL Death Claim Form
• GTL Certificate
• GTL Travel Assist Program
• GTL Policy Amendment

• Supplemental Long Term Disability Election Form
  To enroll, term or make changes to Supplemental Long Term Disability and/or beneficiaries.
• Long Term Disability Conversion Request
  Request for Long Term Disability Conversion Materials.
• Long Term Disability Plan book
  
• LTD Policy Amendment
• LTD Certificate

For the LTD claims packet, please contact your department's benefits representative.

• Health Care Benefit Election Forms
  Most City Employees | SPOG | Local 77
  To enroll in or decline medical insurance.
• Add Benefits/Dependents
  Form used to add benefits.
• Remove Benefits/Dependents
  Form used to delete benefits.
• Aetna Medical Reimbursement Claim Form
  Form used for Aetna reimbursement claims.
• Aetna RX Mail Order Form
  Form used to request prescriptions through mail order.
• PPI Exception Request Form
  
• 2016 Non-IRS Tax Dependents Coverage Values
  

• Active Duty Military Leave
  Information about the new ordinance regarding active military leave.
• Military Continuation of Health Insurance
  Form needed to request continuation of health and other optional insurances for military reservists.
• Limited Power of Attorney
  City of Seattle Ordinance-Leave of Absence and continuation of benefits for military reservists.
• Notice of Intent
  Forms used to give notice of intent to return to City employment from active military leave.

• 2016 Rates
• 2017 Rates
• 2016 Taxable Values
• 2017 Taxable Values

• Paid Parental Leave Program Application

• City of Seattle Privacy Policy
• Vision Provider Privacy Policy
• Dental Health Services Privacy Policy
• Horizon Health Privacy Policy

• Exit Guide for Employees Leaving City Employment
  Information and guidance regarding benefits when employment with the City is terminated voluntarily or involuntarily.
• 2016 Most Employee Benefits Guide
  A reference for use during your employment with the City of Seattle. It will help you make maximum use of your benefits.
• 2016 SPOG Employee Benefits Guide
  This guide is for employees who are members of the Seattle Police Officers' Guild to use as a reference for your employee benefits.
• 2016 Local 77 Employee Benefits Guide
  This guide is for employees who are members of Local 77 I.B.E.W. to use as a reference for your employee benefits
• Benefits Guide for Temporary Benefits-Eligible Employees
  Information and guidance regarding benefits for Temporaries in benefit eligible assignments while actively employed with the City of Seattle.

Page: http://www.seattle.gov/personnel/benefits/library/forms.asp
Printed: 10/1/2016 11:58AM