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. 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 changes to life insurance, accidental death and dismemberment (AD&D) insurance and flexible spending accounts. Coverage begins from date of birth or adoption.
If you have questions or need assistance, contact Benefits, Payroll and Retirement Operations at 206-684-1556 or email@example.com.
Name, Address, Phone, Emergency Contact Change
Submit a Personal Information Update Form to your payroll or human resources representative (not Benefits, Payroll 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.
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 basic information to ensure you receive timely information regarding your benefits.
To update your beneficiaries, click on the following forms links:
When you update beneficiaries, submit your signed original Beneficiary Designation Form and keep a copy for your records.
Regence claim form
Use this Regence claim form to file requests for reimbursement of expenses for medical services proivded under the County's KingCareSM plan.
Add a Dependent (spouse, domestic partner or child)
To add a spouse, domestic partner or child to your coverage, submit the following forms to Benefits, Payroll and Retirement Operations within 30 days after a qualifying life event:
Discontinue Benefit Access Fee
To request that your benefit access fee deductions be stopped, submit the following form to Benefits, Payroll and Retirement Operations (deductions will be stopped at the earliest available payroll cycle):
Appeal Your Family Color Out-of-Pocket Expense Level
Use the Healthy IncentivesSM Appeal Request Form to appeal your 2013 family color out-of-pocket expense level after first appealing to WebMD before Aug. 15 at 1-866-584-6813 (enter the "1" when calling this number).
Request Exemption from Participating in the Healthy IncentivesSM Program
Under exceptional circumstances, you may request an exemption for yourself or a spouse/domestic partner from taking the wellness assessment and participating in an individual action plan. To request an exemption, submit the following form to Benefits, Payroll and Retirement Operations:
Continue Coverage for a Dependent Adult Child
To continue coverage for an adult child, ages 23 – 25, submit this Adult Dependent Enrollment form to Benefits, Payroll and Retirement Operations within 30 days from the date you receive a letter notifying you that you may enroll your dependent in this continued coverage.
Continue Coverage for a Disabled Adult Child
Normally, a dependent child is eligible for benefit coverage until the child turns 25 (coverage ends the last of the month in which the child turns 25). However, you may continue coverage for a child past age 25 if:
- the child is covered under you before turning 25 and;
- is incapacitated due to a developmental or physical disability and;
- is chiefly dependent on you for support.
To continue coverage for a disabled child, submit a Continue Coverage for Disabled Adult Child form to Benefits, Payroll and Retirement Operations no later than 31 days after the child turns 25.
Discontinue Dependent Coverage
Use the Discontinue Dependent Coverage form to discontinue coverage for a dependent.
Discontinue or Reduce Self-Paid Coverage
You may discontinue or reduce self-paid coverage anytime, 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 discontinued or reduced only if a qualifying life event occurs; otherwise, it cannot be discontinued or reduced until the next open enrollment. (For more details, refer to your benefits booklet at Your King County Benefits.)
No form is available to discontinue or reduce self-paid coverage; you must submit a written request to Benefits, Payroll and Retirement Operations, The Chinook Building CNK-ES-O240, 401 Fifth Ave., Seattle, WA 98104-2333.
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:
- Divorce/end of your domestic partnership
- Death of your spouse/domestic partner
- Loss of coverage through another employer.
To opt back in, submit the Opt In for Health Coverage form to Benefits, Payroll and Retirment Operations.
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.
Leaving County Employment
Use the Leaving County Employment form to let your supervisor, payroll/human resources representative and Benefits, Payroll and Retirement Operations know you are ending county employment.
Flexible Spending Account Enrollment
Use the Flexible Spending Account Enrollment form in the FSA Guide to enroll in a flexible spending account when you first become a county employee.
Flexible Spending Account (FSA) Change Form
Submit the Flexible Spending Account Change form to Benefits, Payroll and Retirement Operations to request changes to your flexible spending account. Benefits and Retirement Operations will verify the changes and forward them to FBMC if they qualify.
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 Letter of Medical Need
Submit a Letter of Medical Need with your FSA Reimbursement Claim Form if the expense:
- can be provided for both a medical purpose and a cosmetic, personal, living and/or family purpose, and/or
- is a capital expenditure, which means the item you've purchased has a useful life extending beyond the end of the taxable year. FSA Authorization for Automatic Reimbursement Deposits Form
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
To take a leave of absence for a family or medical leave condition, an employee must ask an approved health care provider to certify the condition by completing and signing one of the following medical certification forms:
Leave of Absence Without Pay Request
An employee must submit this Leave of Absence Without Pay Request Form (pdf version) or (fill-in Word version) to request leave without pay.
Activities Prescription Form
An employee who has medical restrictions and might need accommodation when returning to work must submit this Activities Prescription 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 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.
Direct Deposit Form
Use this Payroll Direct Deposit Authorization Agreement to authorize Payroll Operations to deposit your paycheck directly to your bank, savings or credit union account. Send the form to Benefits, Payroll and Retirement Operations at CNK-ES-0230.
Back-Benefit Cost Worksheet
Staff uses this Back-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, Payroll 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, Payroll 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, Payroll and Retirement Operations for processing their enrollment in the Washington state retirement system.
VEBA enrollment form
Use this VEBA enrollment form to enroll in a VEBA within 12 months of your retirement date.