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Forms

    • HDHP with HSA Deductible Form

      This form is to be used to submit proof of having met an annual HDHP deductible and allow submission of General Purpose Health Care FSA claims.


    • Health Care Flexible Spending Account Midyear Enrollment Form

      This form is to be used for midyear enrollment (i.e. returning from a leave of absence, life event change) in the Health Care Flexible Spending Account. This form is not to be used during the annual open enrollment period, if you wish to enroll during that time you may do so via www.michigan.gov/selfserv.


    • Dependent Care Flexible Spending Account Midyear Enrollment Form

      This form is to be used for midyear enrollment (i.e. returning from a leave of absence, life event change) in the Dependent Care Flexible Spending Account. Note: This form is not to be used during the annual open enrollment period, if you wish to enroll during that time you may do so via www.michigan.gov/selfserv.


    • Life Event/Election Change Form

      This form is to be used by employees who are already enrolled in a FSA to report a qualified life event in either the Health Care or Dependent Care Spending Account for the current calendar year.


    • Health Care Flexible Spending Account Continuation of Coverage

      This form is to be used by eligible employees who wish to continue their enrollment in the Health Care Flexible Spending Account after a retirement or departure. This form authorizes the State to deduct the Remainder of their balance from their last paycheck.

    • Qualified Transportation Fringe Benefits Reimbursement Claim Form CS-1779

      The Qualified Transportation Fringe Benefits Reimbursement Claim Form is accessible through the HRMN Self Service Application or the Michigan Civil Service Commission Website. Once the employee completes the form, it should be mailed with any parking receipts to Qualified Parking, Employee Benefits Division, Civil Service Commission. Reimbursements for parking will be processed through HRMN and will be included in the bi-weekly payroll check.

    • Life Conversion

      This document contain information about continuing your life insurance benefits, a conversion form, and contact information.