Benefits Forms

Records Building - 500 Elm Street, Suite 4100, Dallas, TX 75202
Phone: (214) 653-7638 • Fax: (214) 653-7608

Benefits Forms

For convenience, these forms are also available in Oracle Fusion.

Click on the icon to download the form(s) to your computer.
BlueCross BlueShield Disabled Dependent formacrobat icon
Benefits Enrollment Application for PY2025 - Changes Onlyacrobat icon
Certification of Other Comparable Coverage - MEDICAL OPT OUT for PY2025acrobat icon
Life Insurance Application - Hartfordacrobat icon
Grandchild Affidavitacrobat
Long Term Disability Formacrobat
Spouse Medical Plan Surcharge Affidavit

  • To be completed if you are enrolling your spouse in your employer medical plan (PPO Plan or HDP, including retiree PMD/PSD). If you are NOT enrolling your spouse in your employer medical plan you do not need to complete the electronic submission. If you fail to complete the electronic submission or are late submitting it and you enroll your spouse in your employer medical plan, a $200.00 per month surcharge will be assessed every month until the electronic submission is completed. NO REFUNDS!

    Click here for instructions on submitting a Spouse Medical Plan Surcharge Affidavit
Request for Continued Access to Providersacrobat