FORMS

Flexible Spending Account (FSA) Forms 

• 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. 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.

• 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. 
   

• WageWorks Health Care Account Pay Me Back Claim Form
  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 877-924-3967 or the Employee Benefits Division at 800-505-5011.

• WageWorks Dependent Care Account Pay Me Back Claim Form
  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 877-924-3967 or the Employee Benefits Division at 800-505-5011. 
   
• WageWorks Cardhold Agreement
  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.  

• Qualified Transportation Fringe Benefits Enrollment CS-1776
  The Qualified Transportation Fringe Benefits Enrollment Form is intended for employees not currently having payroll deductions taken for parking reimbursement on a pre-tax basis. The enrollment 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 to the MI HR Service Center. 

• 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. 

• State Health Plan PPO Disabled Dependent Application 
  This form is used by State of Michigan Employees and Blue Cross Blue Shield of Michigan (BCBSM) to determine eligibility of incapacitated dependents for the purpose of continuing benefit coverage past age 19.  Submit the completed for the BCBSM
   
• Accidental Death & Dismemberment Insurance Enrollment Form
   
• Application for Continuation of Insurances
  Employees who go on a leave of absence, are separated, or laid off must complete section II of this form within 60 days of the employees loss of coverage to have the opportunity to continue their benefits through COBRA. (Employees should request this form from their Human Resource Office of Disability Management Office as they will need to complete section I of the form.)
   
• Enrollment Application - Health, Vision, Dental, Life, FSA and LTD Plans
  This form is used by MI HR and Employee Benefits. The form is also used by Legislative Service Bureau, Auditor General, and Judicial employees, and it should be returned to the MI HR Service Center when completed.
   
• Life Insurance and Accidental Duty Death Beneficiary Designation Change 
  This form should be completed by employees to change or add beneficiaries. This form must be returned to your Human Resource Office. 
   

• VDT/CRT Reimbursement Form for Glasses 
  This form is to be completed by an employee who is requesting their Department to pay for a set of frames and lenses to be used with VDT/CRT screens. This form must be accompanied by a copy of the provider's bill and proof of payment (receipt, canceled check, etc.). 

• Verification of Eligibility Form 
  This form should be completed by employees who have eligible dependents between the ages of 19 up to their 25th birthday to continue enrollment in State sponsored dental and/or vision plans.

• Family Medical Leave of Absence Form 
  This form is to be used by Human Resource Offices to notify Employee Benefits of an employee going on FMLA. Employee Benefits uses this to bill the employee and departments for their share of the insurance premiums. 
   

• Plan C Leave of Absence Form 
  This form is to be used by Human Resource Offices to notify Employee Benefits of an employee going on a Plan C Leave of Absence, for insurance premium adjustments.

• Notice of Death 
  This form is completed by Human Resources, Office of Retirement Services, and Employee Benefits. 

• Beneficiary Statement 
  This form is completed by the beneficiary(ies) and is returned to the Human Resource Office, Office of Retirement Services, or Employee Benefits. 

• Preference Beneficiary Statement 
  This form is completed by the employee's family member if no named beneficiary or if named beneficiary is deceased.  Return the form to the Human Resource Office, Office of Retirement Services, or Employee Benefits. 

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