Forms
In most cases, if you are making changes to your benefits due to a qualifying life event (for example, birth of a child), you must make those changes within 30 days of the event. Some benefit changes must be made online, using the county's new online benefits system, while other changes must be completed on paper. The lists below outline the various changes and methods used.
Online Changes
The following changes must be made using the county's online benefits system, My Benefits.
- Marriage/Domestic Partnership
- Spouse/Domestic Partner Lost Medical Coverage
- Change Benefit Access Fee
- Birth/Adoption
- Add/Change Children Coverage
- Discontinue Dependent Coverage
- Employee Lost Medical Coverage
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Sidenote: For newborns and newly adopted children, you have 60 days from the date of birth or adoption to add the child to your benefits, but only 30 days to make life insurance, AD&D insurance and flexible spending account changes. Coverage begins from date of birth or adoption.
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Simply click the appropriate link above to go to the
My Benefits sign in page. Follow the
instructions to sign in to your benefits account and then click the My
Life Events link on the left side of your screen. If you have questions
or need assistance, contact Benefits and Retirement Operations by phone at
206-684-1556 or by
e-mail at: kc.benefits@kingcounty.gov.
Paper Changes
The following information provides a brief outline of the changes that can be made on paper and a link to the appropriate form:
Name, Address, Phone, Emergency Contact Change
Submit a Personal Information Update Form to your payroll or human resources representative (not Benefits and Retirement Operations) to update your name, mailing and home addresses, phone number and emergency contacts - the person you want the county to contact in the event of an emergency.
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The payroll system is the source of information used to administer your benefits. Keep your payroll or human resources representative up to date to with this basis information to ensure you receive timely information regarding your benefits.
Add or change spouse/domestic partner
To add or change a spouse/domestic partner, submit the following three forms to Benefits and Retirement Operations within 30 days of the qualifying life event:
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Discontinue Benefit Access Fee
To request that your benefit access fee deductions be stopped, submit the following form to Benefits and Retirement Operations (deductions will be stopped at the earliest available payroll cycle):
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Request Exemption from Taking the Wellness Assessment
Under exceptional circumstances, you may request an exemption for yourself or a spouse/domestic partner from taking the wellness assessment. To request an exemption, submit the following form to Benefits and Retirement Operations:
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Continue Coverage for Disabled Adult Child
Normally, a dependent child is eligible for benefit coverage until the child turns 23 (coverage ends the last of the month in which the child turns 23). However, you may continue coverage for a child past age 23 if:
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- the child is covered under you before turning 23 and;
- is incapacitated due to a developmental or physical disability and;
- is chiefly dependent on you for support.
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To continue coverage for a disabled child, submit a Continue Coverage for Disabled Adult Child form no later than 31 days after the child turns 23.
Discontinue or Reduce Self-Paid Coverage
You may discontinue or reduce self-paid coverage any time, except if you are a member of the part-time Local 587 and pay for the Partial Benefits Plan through payroll deduction before-tax. Before-tax health coverage may be dropped or reduced only if a qualifying life event occurs; otherwise, not until the next open enrollment. (For more details, refer to your Important Facts booklet.)
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No form is available to drop or reduce self-paid coverage; you must submit a written request to Benefits and Retirement Operations:
Address: New County Office Building MLK-ES-O240, 401 Fifth Ave., Seattle, WA 98104-2333.
Fax: 206-296-7700
E-mail: kc.benefits@kingcounty.gov.
Opt In for Coverage
When you opt out of county health coverage because you have other coverage through your spouse, domestic partner or another employer, you may opt in for health coverage when you lose the other coverage due to:
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- Divorce/end of your domestic partnership
- Death of your spouse/domestic partner
- Loss of coverage through another employer.
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To opt back in, use the Opt In for Health Coverage form.
Update Beneficiaries
To update your beneficiaries, click on the following forms links:
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- Life Insurance
- Accidental Death and Dismemberment Insurance
- Long Term Disability Insurance
- State Retirement System
- Deferred Compensation
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When you update beneficiaries, submit your signed original Beneficiary Designation Form and keep a copy for your records.
Evidence of Insurability
Use the Evidence of Insurability Statement to provide information about a spouse/domestic partner's health to Aetna when you want to purchase Spouse/Domestic Partner Life Insurance in an amount exceeding $100,000.
Termination Notice
Use the Termination Notice to let your supervisor, payroll/human resources representative and Benefits and Retirement Operations know you are ending county employment.
Flexible Spending Account Enrollment Form
The FSA Enrollment form is also included in the FSA Guide, which provides useful information about flexible spending accounts (FSAs). Submit the form to Benefits and Retirement Operations within 30 days of beginning your county health benefits.
FSA Reimbursement Claim Form
An FSA Reimbursement Claim Form is available by request (or on the Web site) from Fringe Benefits Management Company (FBMC), which administers FSAs for King County. You may submit the forms to FBMC as you incur eligible expenses during the calendar year. You may also submit forms until March 31 for previous year expenses.
FSA Authorization for Automatic Reimbursement Deposits Form
Submit the Authorization for Automatic Reimbursement Deposits Form to FBMC to have reimbursements directly deposited to your checking or savings account. The form is also available on the FBMC Web site or by request from FBMC. You may set up direct deposit at any time.
Family and Medical Leave Request
An employee requesting family-medical leave must submit a Protected Family and Medical Leave Request Form (pdf Version) or (fill-in Word Version) to his/her leave-granting authority.
Family and Medical Leave Request Response
An employee's leave-granting authority uses the Protected Family and Medical Leave Response Form (pdf Version) or (fill-in Word version) to respond to a family-medical leave request.
Family and Medical Leave Medical Certification
An approved health care provider must use the Protected Family and Medical Leave Medical Certification to certify an employee's need for family-medical leave and periodic medical evaluations during family-medical leave.
Leave of Absence Without Pay Request
An employee must submit this Leave of Absence Without Pay Request Form (pdf version) or Leave of Absence Without Pay Request Form (fill-in Word version) to request leave without pay.
Physical Capacities Evaluation
An employee who has medical restrictions and might need accommodation when returning to work must submit this Physical Capacities Evaluation Form. If you need help completing this form, contact your safety and claims representative.
Uniformed Services Leave Form
An employee who is going on leave for military training or active service must submit this Uniformed Services Leave Form (pdf version) or (fill-in Word version) to his/her department military leave coordinator.
Leave Donation Form
An employee uses this Leave Donation Form (pdf version) or Leave Donation Form (fill-in Word version) to donate leave accruals to another employee. If you need help with this form, the Donated Leave Chart provides comprehensive information regarding donated leave including union contract information, minimum and maximum hours and conversion data. If you have questions about the donated leave chart, please contact your human resource or service delivery manager.
Temp to TLT Benefit Cost Worksheet
Human resources and payroll staff uses this Temp to TLT Benefit Cost Worksheet to calculate retroactive benefits for a temporary employee moving into a term-limited temporary (TLT) position.
Position Eligibilty Worksheet
Human resources staff completes this Position Eligibility Worksheet (pdf version) or Position Eligibility Worksheet (fill-in Word version) and sends it to Benefits and Retirement Operations to determine whether a position is eligible for participation in the Washington state retirement system.
Retirement Status Form
Human resources staff sends this Retirement Status Form (pdf version) or Retirement Status Form (fill-in Word version) to Benefits and Retirement Operations after new employees complete the first section of the form. Benefits and Retirement Operations completes the remainder of the form and keeps it on file, as required by RCW 41.50.139.
DRS Member Information Form
Employees complete this DRS Member Information Form to elect either PERS 2 or PERS 3 and send it to Benefits and Retirement Operations for processing their enrollment in the Washington state retirement system..
Current
for 2008.
