2022-2023 Benefit Enrollment/Change Forms
2022-2023 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.
2022-2023 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.
2022-2023 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.
2022-2023 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.
2022-2023 – 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
2022-2023 – 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
2022-2023 – 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.
2021-2022 Benefit Enrollment/Change Forms
2021-2022 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.
2021-2022 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.
2021-2022 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.
2021-2022 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.
2021-2022 – 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
2021-2022 – 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
2021-2022 – 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.
2020-2021 Benefit Enrollment/Change Forms
2020-2021 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.
2020-2021 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.
2020-2021 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.
2020-2021 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.
2020-2021 – 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
2020-2021 – 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
2020-2021 – 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.
2019-2020 Benefit Enrollment/Change Forms
2019-2020 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.
2019-2020 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.
2019-2020 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.
2019-2020 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.
2019-2020 – 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
2019-2020 – 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
2019-2020 – 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.
2018-2019 Benefit Enrollment/Change Forms
2018-2019 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.
2018-2019 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.
2018-2019 Licensed & MAPS Employee Midyear Change Form – For licensed and/or MAPS employees, this form is required to make a change to current insurance elections (must have a valid QSC) or beneficiaries.
2018-2019 – 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
2018-2019 – Licensed & 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
2017-2018 Benefit Enrollment/Change Forms
2017-2018 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.
2017-18 Benefit Enrollment Essentials – Use this guide to find out basic information to help guide you through enrollment.
2017-18-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
2017-2018 – Mid-Year Change Form – This form is used for employees that are currently enrolled and need to make a change to their elections (must have a valid QSC) or their beneficiaries.
2017-18 Flex Spending Enrollment Form – This form is to enroll in the Flexible Spending Account plans for both Health Related Expenses as well as Dependent Care Expenses
Wellness Clinic Enrollment Form – This form is used by all benefit eligible employees for initial enrollment. You only need to complete this form if you are waiving other health benefits.
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.
2015-2016 Tax Reporting FAQ’s
2016 ACA 1095 FAQ’s – FAQ sheet regarding 2016 tax reporting/ACA/1095 forms.
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 – Licensed and MAPS– Licensed and MAPS employees use this form to enroll in TSA Plan
Classified 403bTSA Salary Reduction Form – Classified employees use this form to elect salary deferral to participate in TSA Plan
