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Benefits Forms

Although many changes can be done through Employee Self-Service (ESS), eliminating the need to complete and submit a form, some documentation may still be required.  Please make sure to submit all required documentation to the Benefits office within the established timelines.  Otherwise, you will need to wait until the next open enrollment period to make the change.  You can submit forms through interoffice mail, USPS mail, or by scanning the form and submitting it via email.

 

Commonly Used Forms

 

Dependent Eligibility Verification Form

Qualifying Life Event Information

 

Opt Out Note: Part Time employees (less than 40 hours) and Full Time employees (with proof of other coverage) may opt-out of medical, dental and/or vision insurance if done so within one of the following parameters:

  • The first 30 days of benefits eligibility
  • With an applicable qualifying event
  • During the annual open enrollment period

Please contact the benefits office at (253) 573-2345 or benefits@cityoftacoma.org for the required form and detailed information.

Domestic Partner Enrollment Information
Affidavit of Domestic Partnership- Contact the Benefit Office

Information on Domestic Partnership Imputed Income Rates
Affidavit of Domestic Partnership Termination
Please visit the Plan Information page of this Benefits web site for more information on the plans relating to the forms shown below.

 

Deferred Compensation

MissionSquare Enrollment Packet - Available to all City employees
MissionSquare Name Change Form
MissionSquare Beneficiary Change Form or login at ICMARC.org
MissionSquare Deferral Change Form
MissionSquare Catch-Up Provision Packet
MissionSquare Direct Rollover/Transfer
Co-Provider Transfer to MissionSquare (From Nationwide Only)
Rollover out of MissionSquare

MissionSquare Loan Procedures
MissionSquare Emergency Withdrawal Packet
MissionSquare Loan Payoff Options

Nationwide Enrollment Packet - Available to Local 31 employees only
Nationwide Deferral Change Form
Nationwide Name-Address-Beneficiary Change Form or login at Nationwide.com
Nationwide Loan Application
Nationwide Catch-Up Form
Nationwide Outgoing Rollover Request
Nationwide Incoming Assets Form
Nationwide Special Catch-Up Form

Flexible Spending Forms

 (Submit Directly to Trusteed Plan Services)

FSA Authorization for Direct Deposit

FSA Reimbursement Request

FSA Letter of Medical Necessity

FSA Change in Election Form (Submit to benefits@cityoftacoma.org)

Life and Disability Forms

 (Submit to Human Resources Benefits Office)
Long Term Disability Claims - Contact Benefits for Forms and Information
Medical History Statement Application - Life Insurance or LTD

Short Term Disability

Contact the Benefits Office for a Claim form and Information on this plan

 

Regence and Kaiser Permanente

Related information can be found under Plan Information>Medical Plans

Regence Covid-19 information & Forms 

Regence Claim Reimbursement Form
Regence Mail Order Pharmacy Registration Form (Express Scripts)
  

Kaiser Covid-19 Home Test Reimbursement Form

Kaiser Claim Reimbursement information & Forms (Non-Covid Home Test)

Kaiser Permanente Mail Order New Prescription Form
Kaiser Permanente Mail Order Prescription Transfer Refill Form
Kaiser Permanente Mail Order Prescription Refill Form

Retirement Forms and Links

TERS Retirement Forms - City of Tacoma Retirement
Police/Fire Retirement Pension/Beneficiary Forms - State of Washington (DRS)
Railroad Retirement Board - Tacoma Rail Only

Contact Us

(253) 573-2345
email