| Personnel and Human Services 614 Division Street, MS-23 |
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| Port Orchard, WA, 98366 | |
| Phone: 360.337.7185 Fax: 360.337.7187 |
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2010 Benefit Forms - Contact the Personnel office at 337-7185 if assistance is needed. Medical Enrollment Forms: required if making changes to medical coverage. Please fill form out completely as it will replace all prior forms on file.Premera Enrollment Form Premera Enrollment Form for Deputy Sheriff Guild members Group Health Enrollment Form Group Health Enrollment Form for Deputy Sheriff Guild members Waiver Form for full-time employees to waive medical coverage and part-time employees to waive medical, dental, vision and/or life insurance coverage Spousal Surcharge Disclosure Form - required to change spousal surcharge status NOTE: Dental, Vision and Life Insurance Changes: For open enrollment, all changes to dental, VSP vision and life insurance coverage are to be completed on line. Access to the website will be available after November 2nd and information and links will be provided here. Flexible Spending Arrangements (FSA's): New election required each plan year! Day Care or Health Care FSA Account Information Day Care/Health Care Enrollment Form for 2010 Transportation FSA Account Information Transportation FSA Enrollment Form for 2010 Beneficiary Change Forms Standard Life Insurance Retirement Miscellaneous Forms Address Change Form W-4 |
Last Updated:
November 14, 2009
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