Forms

General Forms

Please Return Completed Forms to Human Resources

• Decedent’s Warrant (PDF)
• Direct Deposit (PDF)
• Leave Donations (PDF)
• Request for Donated Leave (PDF)
• FMLA Employee Packet (PDF)
• Pregnancy Related Medical Leave Form (PDF)
• Authorization to Release Information (PDF)

Benefits Forms

Return Completed Forms to Human Resources

• Blood Screening Verification (PDF)
• Direct Deposit of Flex Reimbursement (PDF)
• Declaration of Domestic Partnership (PDF)
• Supplemental Vision Enrollment Form (DOC)
• Flexible Benefits Enrollment Form (PDF)
• Joint Processing Form (PDF)
• Request for Health Plan Enrollment Change (PDF)

Return the Following Forms to Allegiance

• Medical Claim Form (PDF)
• Medical Flex Claim Form (PDF)
• Dependent Care FSA Reimbursement Request Form (PDF)
• Daycare Reimbursement Contract (PDF)

Pharmacy Benefit Forms

• Ridgeway Drug Mail Order Form (PDF)
• Costco Mail Order Service: Please contact HR Office for instructions.

Deferred Compensation

Return the Deferred Compensation Plans forms to the Human Resources Office.