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.
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 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.
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.
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.
Eligible employees must have their HR office complete and submit the Specialty Glasses Employee Certification Form on their behalf. 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 Computer and Safety Glasses page for more info.
This form is used by State of Michigan Employees and BCBSM/BCN to determine eligibility of incapacitated dependents for the purpose of continuing benefit coverage past age 26. Submit the completed form to BCBSM/BCN.
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.)
This form should be completed by employees to change or add beneficiaries. This form must be returned to your Human Resource Office.
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.
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.
This document contain information about continuing your life insurance benefits, a conversion form, and contact information.
