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. 

• Health Care Flexible Spending Account Continuation of Coverage 
  This form is to be used by eligible employees who wish to continue their enrollment in the Health Care Flexible Spending Account after a retirement or departure. This form authorizes the State to deduct the Remainder of their balance from their last paycheck. 
  
  

• WageWorks Health Care Account Pay Me Back 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 WageWorks at 1-877-924-3967 or the Employee Benefits Division at 1-800-505-5011.

• WageWorks Dependent Care Account Pay Me Back 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 WageWorks at 1-877-924-3967 or the Employee Benefits Division at 1-800-505-5011. 
  

• Qualified Transportation Fringe Benefits Enrollment CS-1776
  The Qualified Transportation Fringe Benefits Enrollment 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. Once the employee completes the form, it should be mailed to the MI HR Service Center. 

• Qualified Transportation Fringe Benefits Reimbursement Claim Form CS-1779 
  The Qualified Transportation Fringe Benefits Reimbursement Claim 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. 

• State Health Plan PPO Disabled Dependent Application 
  This form is used by State of Michigan Employees to determine eligibility of incapacitated dependents for the purpose of continuing benefit coverage past age 19. 
  
  
• Accidental Death & Dismemberment Insurance Enrollment Form
  
  
• 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 is used by MI HR and Employee Benefits. The form is also used by Legislative Service Bureau, Auditor General, Attorney General, Secretary of State, and Judicial employees, and it should be returned to their Human Resource Office when completed.
  
  
• 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
  This form is used by MI HR and Employee Benefits. The form is also used by Legislative Service Bureau, Auditor General, Attorney General, Secretary of State, and Judicial employees, and it should be returned to their Human Resource Office when completed.
  
  
• 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 Eligibility Form 
  This form has two sections. Section 1 is "Student Verification of Eligibility". This section 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 plans. Section 2 is "Adult Child Verification of Eligibility". This section should be used by employees to certify their adult child's eligibility to remain on their parent's or legal guardian's health plan until age 26.

• 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.

• Notice of Death 
  This form is completed by Human Resources, Office of Retirement Services, and Employee Benefits. 

• Beneficiary Statement 
  This form is completed by the beneficiary(ies) and is returned to the Human Resource Office, Office of Retirement Services, or Employee Benefits. 

• Preference Beneficiary Statement 
  This form is completed by the employee's family member if no named beneficiary or if named beneficiary is deceased.  Return the form to the Human Resource Office, Office of Retirement Services, or Employee Benefits. 

• Life Conversion
  This document contain information about continuing your life insurance benefits, a conversion form, and contact information.