Flexible Spending Account (FSA) Forms

• Health Care Spending Account Midyear Enrollment Form
  This form is to be used by employees to enroll in the Health Care Spending Account.

• Dependent Care Spending Account Midyear Enrollment Form
  This form is to be used by employees to enroll in the Dependent Care Spending Account.

• Life Event/Election Change Form
  This form is to be used by employees to report a qualified life event in either the Health Care or Dependent Care Spending Account for the current calendar year.

• ADP FSA Card Expense Substantiation Form
  This form is to be used by employees when faxing or mailing receipts and other necessary documentation to verify Medical Care Spending Account expenses.  Use this form only if your FSA Debit Card was used to pay for the expense and you received a request for substantiation from ADP.
  
  
• ADP Health Care Spending Account Claim Form
  This form is to be used by employees with a Health Care Spending Account to request reimbursement for their eligible expenses.  If employees have questions, they may contact ADP at 1-800-422-3703 or the Employee Benefits Division at 1-800-505-5011.
  
  
• ADP Dependent Care Spending Account Claim Form
  This form is to be used by employees with a Dependent Care Spending Account to request reimbursement for their eligible expenses.  If employees have questions, they may contact ADP at 1-800-422-3703 or the Employee Benefits Division at 1-800-505-5011.

• Qualified Parking Account Reimbursement
  The Qualified Parking Spending Account Reimbursement Form is accessible through the HRMN Self Service Application or the Michigan Civil Service Commission Website. Once the employee completes the form, it should be mailed with any parking receipts to Qualified Parking, Employee Benefits Division, Civil Service Commission. Reimbursements for parking will be processed through HRMN and will be included in the bi-weekly payroll check.

• Qualified Parking Spending Account Enrollment/Change
  The Qualified Parking Spending Account Enrollment/Change Form is intended for employees not currently having payroll deductions taken for parking reimbursement on a pre-tax basis. The enrollment form is accessible through the HRMN Self Service Application or the Michigan Civil Service Commission Website. The maximum monthly deduction for parking is $195 (or $90 per pay period). Once the employee completes the form, it should be mailed to the MI HR Service Center.

• Application for Continuation of Insurances
  Employees who go on a leave of absence, are separated, or laid off must fill out the this form within 60 days of the employees loss of coverage to have the opportunity to continue their benefits through COBRA. (Employees should request this form from their Human Resource Office.)
  
  
• Enrollment Application - Health, Vision, and Dental Care Plans
  This form should be completed by employees with a qualifying event and newly hired or reinstated employees for the Health, Vision, Dental Care, Life and LTD insurance plans. This form should be returned to the MI HR Service Center.
  
  

• Life Insurance and Accidental Duty Death Beneficiary Designation Change
  This form should be completed by employees to change or add beneficiaries. This form must be returned to your Human Resource Office.

• Long Term Disability Application
  As a new employee or at open enrollment, this form must be submitted by employees requesting Long-Term Disability benefit coverage. The form is required to be sent to the MI HR Service Center. Please keep a copy.

• Medical Certification of Physician or Practitioner
  When leave is needed to care for a seriously ill-family member, the employee shall fill out this form which states the care he or she will provide and an estimate of the time period during which this care will be provided.

• Medical Certification of Physician or Practitioner
  When leave is needed to care for a seriously ill-family member, the employee shall fill out this form which states the care he or she will provide and an estimate of the time period during which this care will be provided.

• Notice of Family and Medical Leave
  FMLA notice is required at the beginning of an employee's absence or when the reason becomes clear to the supervisor that the employer is eligible for FMLA and is abent for a serious health condition.  The supervisor is required to complete, sign and must either give or send a copy to the employee and the original to Human Resources.  Please keep a copy.

• Notification by Employee/Retiree of Qualifying Event
  This form should be filled out by employees who have a qualifying event (divorce, legal separation, dependent child no longer eligible) that causes the loss of state sponsored insurance coverage for their dependent(s). This information is used to notify dependents of their rights to continue insurance coverage. This form must be returned to the Employee Benefits Division.

• VDT/CRT Reimbursement Form for Glasses
  This form is to be completed by an employee who is requesting their Department to pay for a set of frames and lenses to be used with VDT/CRT screens. This form must be accompanied by a copy of the provider's bill and proof of payment (receipt, canceled check, etc.).

• Verification of Dependent Eligibility
  This form should be completed by employees who have eligible dependents between the ages of 19 to 25 to continue enrollment in State sponsored health, dental and/or vision insurance plans. The form should be returned to the Employee Benefits Division with the required documentation.

• Family Medical Leave of Absence Form
  This form is to be used by Human Resource Offices to notify Employee Benefits of an employee going on FMLA. Employee Benefits uses this to bill the employee and departments for their share of the insurance premiums.

• Plan C Leave of Absence Form
  This form is to be used by Human Resource Offices to notify Employee Benefits of an employee going on a Plan C Leave of Absence, for insurance premium adjustments.