Forms

Complete your 2023 Eligibility Form Electronically (Click Here)

OTC Covid Test Reimbursement Form (Click Here)
*You are able to get 4 free Covid-19 test kits by visiting https://www.covidtests.gov & though the State of Iowa by visiting https://www.testiowa.com.

2023 Continued Eligibility Verification Form

Spouse Declaration Form

Dependent Declaration Form

Initial Enrollment Form 

Enrollment Addition Form (New Spouse/Child) 

HRA Claim Form 

Fitness Membership/Health Class RX Form 

Death Benefit Beneficiary Form 

Local Pension Beneficiary Form 

PHI Authorization Form (Protected Health Information) 

Injury Detail Form 

Short-term Disability Form 

Dental & HRA Opt Out Forms