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.
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.
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.
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.
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.
This form is to be used by employees with a Dependent Care Spending Account to request reimbursement for their eligible expenses. If employees have questions, they may contact WageWorks at 1-877-924-3967 or the Employee Benefits Division at 1-800-505-5011.
This form is to be used by employees with a Health Care Spending Account to request reimbursement for their eligible expenses. If employees have questions, they may contact WageWorks at 1-877-924-3967 or the Employee Benefits Division at 1-800-505-5011.
In order to use the Card, you must agree to abide by the terms and conditions of the Plan, as set forth in the Cardholder Agreement.
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.
This form is used by State of Michigan employees/retirees and Blue Cross or BCN to assist EBD in determining eligibility of incapacitated children for the purpose of continuing benefit coverage past age 26. Submit the completed form to Blue Cross/BCN.
This form is used by State of Michigan employees and C.O.P.S. Health Trust to assist EBD in determining eligibility of incapacitated children for the purpose of continuing benefit coverage past age 26. Submit the completed form to C.O.P.S. Health Trust.
This form is used by State of Michigan employees/retirees and HAP to assist EBD in determining eligibility of incapacitated children for the purpose of continuing benefit coverage past age 26. Submit the completed form to HAP.
This form should be completed by employees to change or add beneficiaries. This form must be returned to your Human Resource Office.
Eligible employees must have their HR office complete and submit the Specialty Glasses Employee Certification Form on their behalf for prescription safety glasses. After the form is submitted, there is a processing period of three business days. Once the form has been processed, the employee will have a 60-day window to visit their eye doctor and fill the prescription. View the Specialty Glasses page for more info.
This form should be completed by employees who have eligible grandchildren they'd like to cover on their benefits if the parent of the grandchild is between the ages of 19 up to their 25th birthday and is regularly attending an accredited educational institution.
