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

    2014-2015 Medical Waiver Form   -  All employees who choose the medical
waiver need to complete a new  form yearly

    2014-2015 Medical Premium Costs

 Summary of Benefits and Coverage –  Plan A

 Summary of Benefits and Coverage –  Plan B

 Summary of Benefits and Coverage –  Plan C

 Summary of Benefits and Coverage –  HDHP

   Wellmark Application-  Use this form to change plans at open enrollment

   Primary Care Provider Selection Form Plan B or C Use this form with
Plan B and Plan C

    2014-2015 Employee HSA Enrollment Form

    2014-2015 Employee HSA Payroll Deduction Form

    Wellmark Preventive Services covered under The Affordable Care Act

    Glossary of Terms

    Plan A Certificate

    Plan B Certificate

    Plan C Certificate

    HDHP Certificate 

Dental/Vision

     2014-2015 DENTAL Vision Rates

Summary of Benefits and Covereage Dental and Vision

    Dental/Vision 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

     2014-2015 FSA Election Form  -  Use this form at open enrollment to make
changes to your flex spending  accounts or to add a flex spending account

     BeneFIT Access Claim Form

     Employee Portal QuickStart Guide

     BeneFIT Access Mobile

     Flex Spending Account Information

     Orthodontia Information

 

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

    2014-2015 Coast to Coast Vision Plan  –  A new enrollment is required each year of participation

    2014-2015 Coast to Coast Providers

Tuition Remission/Exchange

     Tuition Remission Application

     Tuition Exchange Application

Voluntary Time Schedule Reduction

Letter of Agreement

Voluntary Schedule Reduction 

Application 

Payroll Forms

       Direct Deposit 

       Check by Mail - authorization form for Simpson to mail your wages

Federal W-4

Iowa W-4

I-9

 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.

SSA Name Change