Forms: Employee Benefits

Medical, Pharmacy, Vision, Dental & Life Insurance Forms:

OEBB Enrollment and Change Form - for initial enrollment as well as mid-year changes due to qualified status change (QSC) events

OEBB Appeal Form - if you made a mistake during Open Enrollment and want OEBB's permission to correct it, submit this form directly to them

OEBB Affidavit of Dependency - for eligible children whom you or your spouse/domestic partner are obligated to support, or contribute to the support of, and who are not a biological or adopted child (of either you or your spouse/domestic partner).  Not required for step-children or children of domestic partners.

Wellness Clinic Only Enrollment Form - if you have benefits-eligible dependents you choose not to cover on your health insurance, but would like them to have access to the 4J Wellness Clinic, submit this form to 4J Human Resources

ACH Form– authorization for automatic withdrawal from your bank account

Mail Order Pharmacy Form

Domestic Partner Forms:

Affidavit of Domestic Partnership Form - be sure you know all the tax implications of adding a domestic partner to your coverage before doing so (see FAQ's) 

Termination of Domestic Partnership Form

Direct Member Reimbursement Forms:

(for use when you pay cash for a covered service and need to submit receipt to ODS for reimbursement)

     Medical/Vision

     Dental

     Prescriptions

Long-Term Disability (LTD) Forms:

Long-Term Disability Online Claim Submissions

Long-Term Disability Printable Claim Form

Manley Flexible Spending Account (FSA) Forms:

FSA Claim/Reimbursement Form– to submit receipts if you're already enrolled

FSA Enrollment Form

FSA Change Form– to update contact information or change dependent care contribution amount (Note: Heathcare FSA amounts cannot be changed for any reason.  Only Dependent Care amounts may be changed within 31 days of a qualified status change event.)

FSA Direct Deposit Form– to authorize deposit reimbursements into your bank account

Forms No Longer Available:

Incapacitated (Disabled) Dependent Certification - OEBB and ODS no longer provide a form for certifying the disability of a dependent over age 26.  Simply provide documentation of the disability as described in the Plan Book.  (Click here for details.)