Forms

  • Employee Forms

    Application for continuation of coverage for a child 26 or older who is mentally or physically disabled.(Updated October 2013)

    Form for direct pay retiree, surviving spouse, and COBRA. (Updated March 2012)

    Most agencies submit leave information to ERS monthly. Agencies that do not must complete this form and send to ERS.

    Certify children for coverage. (Updated August 2013)


    Complete this form if you are diagnosed by a physician as having a health factor that prevents you from discontinuing the use of Tobacco Products. (Updated July 2013)

    Use this form to select a primary care physician and to provide other insurance information to your health plan after. (Updated October 2012)

    Updated October 8, 2014


    Used to notify ERS that emergency medical attention is needed for a member/dependent(s) coverage NOT shown on carrier’s system. (Updated February 2012)

    Participant fills in appropriate sections of the form. The benefits coordinator completes the form and sends to ERS. (Updated February 2012)

  • Other Forms

    Form for direct pay retiree, surviving spouse, and COBRA. (Updated March 2012)

    Used by retirees and direct pay participants to send in payments for insurance. (Updated October 2012)

    Used by former employees and retirees to make payments towards a TexFlex Healthcare account after they leave employment. (Updated October 2012)