Benefits Forms

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


Benefits Forms

 

Click on the icon to download the form(s) to your computer.
Benefits Enrollment Application for PY2022 - Changes Onlyacrobat icon
Benefits Enrollment Application for PY2021 - Changes Onlyacrobat icon
Certification of Other Comparable Coverage - MEDICAL OPT OUT - PY2022acrobat 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