Benefit Forms

Need an enrollment or change form? How about a claim form? All pertinant medical, dental, life insurance and flexible spending account forms can be found below

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VEBA and Medical Flex Claim form (pdf, 349 KB)

VEBA and FSA Medical Claim form for reimbursement

Flex Daycare Claim form (pdf, 342 KB)

Flex Spending Account Dependent Day Care claim form

VEBA Freeze Form (pdf, 347 KB)

If you or your spouse has access to an HSA, your VEBA must be frozen while the HSA is active. You may use the same form to un-freeze your VEBA.

PreferredOne Enrollment/Change form (pdf, 746 KB)

Medical enrollment/change form for 2014-2015

Flexible Spending Account Enrollment/Change form (pdf, 975 KB)

Enrollment form for the Flex Spending Medical and/or Daycare Plan

Community Ed Wellness Reimbursement Form (pdf, 254 KB)

To be reimbursed for a Community Education class taken through Hopkins by an employee.

Genesis Recurring Reimbursement Form (pdf, 483 KB)

For retiree's who wish to be automatically reimbursed for their premium payments from their VEBA. (Not applicable to active staff.)

Dental Insurance Enrollment Form (pdf, 702 KB)

Dental Insurance Enrollment Form