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

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.

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, Payroll and Retirement Operations at 206-684-1556 or  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, 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.

Add or Change Spouse/Domestic Partner

To add or change a spouse/domestic partner, submit the following three forms to Benefits, Payroll and Retirement Operations within 30 days of the qualifying life event:

• Add Dependent
• Affidavit of Marriage/Domestic Partnership
• Benefit Access Fee Election .

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):

• Request to Discontinue Benefit Access Fee

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, Payroll and Retirement Operations:

• Wellness Assessment Exception Request Form 

Appeal Healthy Incentives^SM Out-of-Pocket Expense Level

If you want to appeal the out-of-pocket expense level you've received for your 2010 medical benefits, you must first appeal to Healthways between Aug. 1 and Aug. 31, 2009. The Healthways phone number is 1-877-279-0624.

If you disagree with Healthways’ decision concerning your appeal, you may then ask the county for an additional review – however, the county will not consider an additional review if you have not first appealed to Healthways. To ask the county for the additional review, submit the following form to Benefits, Payroll and Retirement Operations no later than Sept. 15, 2009:

• Healthy Incentives^SM Appeal Request Form (pdf version)
• Healthy Incentives^SM Appeal Request Form (fill-in Word version) 

Continue Coverage for a Dependent Adult Child

You may continue medical, dental, vision and accidental death and dismemberment (AD&D) coverage for your unmarried, eligible dependent who is 23 or 24 years old. When you elect to continue coverage for a dependent who is 23 or 24 years old, you pay monthly premiums for the coverage. To continue coverage, submit an 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 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.)

No form is available to drop 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.

Update Beneficiaries

To update your beneficiaries, click on the following forms links:

• Life Insurance
• Accidental Death and Dismemberment Insurance
• Long Term Disability Insurance
• State Retirement System
• Deferred Compensation

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, Payroll and Retirement Operations know you are ending county employment.

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:

• Certification of Health Care Provider for Employee's Serious Health Condition – for a leave to care for your own serious health condition.
• Certification of Health Care Provider for Family Member's Serious Health Condition – for a leave to care for the serious health condition of your qualified family member.
• Certification of Serious Injury or Illness of Covered Servicemember for Military Family Leave – for a leave to care for the serious injury or illness of your qualified military service member.
• Certification of Qualifying Exigency for Military Family Leave – for an exigency leave related to your qualified family member’s military deployment.

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.

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 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.

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, 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.