GBP-eligible employees use this form to request approval to extend GBP coverage for a disabled child beyond age 26.
Form for direct pay retiree, surviving spouse, and COBRA participant to authorize direct withdrawal of monthly insurance premiums from bank accounts.
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.
Disability claim form and Disability EOI form available on the Dearborn website.
Certify children for coverage.
An EOI application is required to enroll in disability insurance coverage unless the employee is within the first 31 days of employment.
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.
Return these completed coupons with your monthly insurance payments to ERS.
Return these completed coupons with your monthly TexFlex payment to ERS. Payments are due on the 1st of every month.
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