Forms and Resources
On this site you may access forms which are available to be viewed and printed. To access any of the following forms, click on the form you are interested in, and then use the print feature in the application it is displayed in. To view PDF files you need to get Adobe Acrobat Reader.
Medical
2013-2014 Medical Waiver Form - All employees who choose the
medical waiver need to complete a new form yearly
2013-2014 SC Health Insurance Rates
2013-2014 Side by Side Health Insurance plan A – B
2013-2014 Side by Side Health Insurance plan C Plan HDHP
2013-2014 Wellmark Application- Use this form to change plans
at open enrollment
2013-2014 Primary Care Provider Selection Form Plan B or C- Use this
form with Plan B and Plan C
2013-2014 HSA Payroll Deduction Form
Wellmark Preventive Services covered under The Affordable Care Act
Dental/Vision
2013-2014 Dental/Vision Rates - Includes Plan Summary
2013-2014 D/V Enrollment Form- Use this form to make address changes, name changes, cancel coverage, add dependents, or to change plans at
open enrollment
VSP Out of Network Claim Form - Use this form if you have an out of network provider
Flexible Spending Accounts
2013-2014 FSA Election Form - Use this form at open enrollment to make changes to your flex spending accounts or to add a flex spending account
2013 Flex Spending Account Information
Flex Account Reimbursement Direct Deposit Form
Life Insurance
Life Insurance Enrollment Form - Use this form for new hires and to change beneficiaries
Evidence of Insurability Form - Use this form if you want to add additional optional coverage
Coast to Coast Vision Plan
2013-2014 SC Coast to Coast Enrollment Form – A new enrollment is required each year of participation
Tuition Remission/Exchange
Payroll Forms
Check by Mail - authorization form for Simpson to mail your wages
Federal W-4
Iowa W-4
Name Change
Apply to the Social Security Administration for a new card, provide HR with a copy of the new card to make the change.