2023-2024 Benefit Enrollment/Change Forms

2023-2024 OEBB-Appeal Form – This form is required if you need to challenge a decision made by OEBB or missed an enrollment deadline.  This form gets returned to OEBB directly, the addresses and numbers are on the form itself.

2023-2024 Classified Employee Midyear Change Form– For classified employees, this form is required to make a change to current insurance elections (must have a valid QSC) or beneficiaries.

2023-2024 Licensed Employee Midyear Change Form – For licensed employees, this form is required to make a change to current insurance elections (must have a valid QSC) or beneficiaries.

2023-2024 MAPS Employee Midyear Change Form  – For MAPS employees, this form is required to make a change to current insurance elections (must have a valid QSC) or beneficiaries.

2023-2024 – Classified New Hire Enrollment Form – This form is for new hires and newly benefit eligible employees to complete.  This enrolls them in medical, Rx, dental, and vision coverage.  This form is also used to waive coverage as well as designate beneficiaries.  Health and Medical Plans

2023-2024 – Licensed New Hire Enrollment Form – This form is for new hires and newly benefit eligible employees to complete.  This enrolls them in medical, Rx, dental, and vision coverage.  This form is also used to waive coverage as well as designate beneficiaries.  Health and Medical Plans

2023-2024 – MAPS New Hire Enrollment Form – This form is for new hires and newly benefit eligible employees to complete.  This enrolls them in medical, Rx, dental, and vision coverage.  This form is also used to waive coverage as well as designate beneficiaries.  Health and Medical Plans

FSA Change Form (Pacific Source) – This form is for mid-year changes to Dependent Care FSA only. Please return completed form within 30 days of the change. Please note that the form needs to be returned to Human Resources by the 15th of the month for changes to current month pay cycle.

Other Benefits Related Forms

ACH Form – Please return a signed ACH form to Human Resources if your monthly insurance premium will be paid through your bank. This form is usually used by retirees and employees who are on a leave of absence and not receiving a paycheck.

Affidavit-of-Domestic-Partnership – To add a domestic partner by affidavit to your coverage, you must submit this affidavit

FSA Reimbursement form – This form is to file a claim with PacificSource Administrators to be reimbursed under your FSA plan.  You can also file a claim electronically by using this link as well.

Hire a Spouse Form (fill-able) / Hire a Spouse Form (printable) -This form is needed to confirm or waive eligible dependent coverage continuance after a 4J retiree terminates from the plan due to Medicare eligibility. Please complete this form and submit to 4J Human Resources 30 days prior to retiree coverage ending.

403(b) TSA Salary Reduction form – This form is used to enroll in TSA Plan, add a voluntary deduction, change your voluntary deduction, or end your voluntary deduction.