Employee Benefits

Benefits Forms

Records Building - 500 Elm Street, Suite 4100, Dallas, TX 75202
Phone: (214) 653-6161 • Fax: (214) 653-7608

2026 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 Form
Benefits Enrollment Application for PY2026 - Changes Only
Certification of Other Comparable Coverage - MEDICAL OPT OUT for PY2026
Life Insurance Application - Hartford
Grandchild Affidavit
Long Term Disability Form
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 Providers

2025 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 Form
Benefits Enrollment Application for PY2025 - Changes Only
Certification of Other Comparable Coverage - MEDICAL OPT OUT for PY2025
Life Insurance Application - Hartford
Grandchild Affidavit
Long Term Disability Form
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 Providers