GBP-eligible employees use this form to request approval to extend GBP coverage for a disabled child beyond age 26.
Fillable version of the mail service order form for Caremark.
Most agencies submit leave information to ERS monthly. Agencies that do not must complete this form and send to ERS for certification of leave balances when an employee retires.
Certify children for coverage.
Available on the Minnesota Life website
If you quit using tobacco, or if someone you're covering quits, complete this affidavit attesting to the new tobacco-free status.
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.
Use this form to select a primary care physician and to provide other insurance information to your health plan after. This is NOT an enrollment form and does NOT verify eligibility.
401(k) Beneficiary Designation Form, Direct Rollover Form, and Enrollment Form are available on the Texa$aver website.
457 Beneficiary Designation Form, Transfer/Direct Rollover Form, and Enrollment Form are available on the Texa$aver website.
This form should be used only to notify ERS that emergency medical attention is needed for a member/dependent(s) who does not show coverage on the health insurance carrier’s system.
Participant fills in appropriate sections of the form. The benefits coordinator completes the form and sends to ERS.
Form for direct pay retiree, surviving spouse, and COBRA participant to authorize direct withdrawal of monthly insurance premiums from bank accounts.