Department of Finance & Administration
Dave Goetz, Commissioner
Benefits Administration
Insurance Forms
All files on this page are in Adobe Acrobat format. As a convenience, the PDF forms allow you to fill in the requested information before printing. After filling in the necessary information you may print out the form, sign in the requested fields, and send the form to your agency benefits coordinator (typically located in the human resource section of your department). Please note: The data you fill out on these forms is NOT submitted electronically to your benefits coordinator. A printed form must be submitted to your agency to process any requested changes.
Enrollment/Change Application—State and Higher Education (FA-0820)
Enrollment/Change Application—Local Education (FA-0854)
Enrollment/Change Application—Local Government (FA-0978)
Enrollment/Change Application — Retiree Dental Coverage (FA-1032)
Dependent Eligibility Verification Documents
Provides a list of acceptable documentation which must be submitted to enroll an eligible dependent in coverage. Review the frequently asked questions for additional information.
Request for Extension to Submit Eligibility Documentation (FA-1033)
To be used by those who need additional time to secure dependent eligibility documentation
Intent to Claim Dependent Child on Taxes for Insurance Enrollment (FA-1033)
Basic Life Beneficiary Designation Application (FA-1005)
Application for Special Enrollment by Qualifying Event (FA-0868)
Application for Late Enrollment — Medical Underwriting
Please note: Effective June 1, 2009, the application fee for medical underwriting increased to $75
Application to Continue Insurance at Retirement TCRS (TR-0221)
Application to Continue Insurance at Retirement non-TCRS (FA-0857)
Application for Medicare Supplement TCRS (TR-0395)
Application for Medicare Supplement non-TCRS (FA-0983)
Request for Retroactive Transaction (FA-0938)
Leave Without Pay—State and Higher Ed (FA-0867)
Leave Without Pay—Local Education and Local Government (FA-0953)
Optional Special Accident Enrollment Application (FA-0831)
Optional Term and Universal Life Enrollment Application (AE-1115)
Optional Life Supplemental Application (M-95202)
Flexible Benefits Forms
Enrollment in flexible benefits is handled by Benefits Administration as is any request for a family status change.
Flexible Benefits Plan Enrollment — Medical and Dependent Day Care (FA-1009)
Flexible Benefits Plan Enrollment — Transportation and Parking (FA-1020)
Flexible Benefits — Family Status Change Application (FA-1010)
Reimbursement requests for flexible benefits are handled by the Flexible Benefits Office in the Department of Treasury.
Reimbursement Form - Medical and Dependent Day Care (TR-0332)
