Forms

Forms

• Change of Address
• Automatic Deposit Authorization Form
• INS 100 (Health Benefits Form)
• INS 100 VEBA (Health Benefits Form)
• Application For Retirement
• Reciprocity Fact Sheet Election Form
• Premier One Deduction Authorization Form
• Name Change Form

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Forms > Active

• Beneficiary Designation Form

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Forms > Retirees

• FAQ 2023 Form W-4P and W-4R
• ORS TEFRA Annual Tax Withholding Notice
• IRS Withholding Certificate for Pension or Annuity Payments
• CA State Withholding Certificate for Pension or Annuity Payments

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Forms > Retirees > Anthem

• INS 650 Medicare Transition
• Anthem PPO Enrollment Form
• Anthem HMO Enrollment Form
• Anthem HMO Medicare Sr. Secure Form (Disenrollment)
• Anthem PPO Medicare Preferred Form (Disenrollment)

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Forms > Retirees > Federated

• Beneficiary Designation Tier 1 Federated
• Beneficiary Designation Tier 2 Federated
• Automatic Deduction Election Form

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Forms > Retirees > Kaiser

• Kaiser HI Sr. Advantage Enrollment Form
• Kaiser Northwest Sr Advantage Enrollment Form
• INS 650 Medicare Transition
• KPSA NorCal Enrollment Form CA-Fillable
• KPSA SoCal Enrollment Form CA-Fillable
• Kaiser Sr. Advantage Disenrollment Form (CA-north and south)
• Kaiser Sr. Advantage Disenrollment Form (Hawaii)

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Forms > Retirees > Life Insurance Company of North America

• Life Insurance Company of North America Application

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Forms > Retirees > Police & Fire

• Beneficiary Designation Form
• Automatic Deduction Election Form

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Forms > Retirees > Standard Insurance Company

• Standard Insurance Company Request For Group Life Conversion Materials
• Standard Insurance Company Group Life Portability Insurance Application

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