Documents

2026 Current Employee with Adult Child Notice

Notification and enrollment form for adult dependent children ages 26-30 in available health plans. Applicable to adult children aging off at the end of the month in which they turn age 26 or new enrollment due to lost of other health coverage (status change). Additional premium required.

2025 Retiree with Adult Child Notice

Notification and enrollment form for adult dependent children ages 26-30 in available health plans. Applicable to adult children aging off at the end of the month in which they turn age 26 or new enrollment due to lost of other health coverage (status change). Additional premium required.

Authorization For Release Of Health Information (HIPAA) Form

Interactive form allowing person authorized by employee to address benefits concerns

Benefits Department Data Request Form

Deletion Form

Interactive form used to remove/delete dependents and/or change participation levels (Restrictions Apply)

Dependent Verification Form & FAQ

To verify an eligible dependent(s) prior to enrollment into the Health, Dental and Vision Coverage, in compliance with the District's Dependent Verification Process.

Domestic Partner Enrollment Forms

Interactive Insurance Enrollment Forms and information for adding a domestic partner and dependents

Disenrollment Statement - Domestic Partner

Interactive Insurance Disenrollment Form for deleting a domestic partner and dependents

EAP Formal Referral Form

Interactive Referral Form used by Administrators/Supervisors to request EAP Assistance

Evidence of Insurability Application - Life Insurance

Application used to request enhancement of Life Insurance.

FMLA Application-Instructional Personnel

FMLA Application Non-Instructional Personnel

FMLA Certification - Employee

FMLA Certification - Family Member

FMLA Certification - Exigency Military

FMLA Certification - Current Military

FMLA Certification - Veteran Military

Interactive Application used to request Family Medical Leave - Administrative and Non-Instructional Personnel When submitting an application for FMLA the applicable certification form must be completed and sent directly to the Leaves DepartmentThere are five (5) different certification forms, depending on which leave is being selected. All certification forms must be completed by physician or practitioner and employee. 

HIPAA Release Form

Authorization For Release of Health Information

Leave of Absence Request 

Interactive Application for Board Approved Leave of Absence .

Medco Mail-Order Prescription Form

Form used to order prescriptions via mail-order service from Medco.

Medco Mail-Order Prescription Refill Form

Form used to order refill of prescriptions via mail-order service from Medco.

Newborn Enrollment Form

Interactive form

Opt-Out | Dental

Opt-Out | Medical

Opt-Out | Vision

Interactive forms used to request a declination of Medical, Dental and Vision Insurance Coverage for School Board Employee.

MetLife Absence Reporting Guide

Instructions for filing a (MetLife) disability claim by telephone

Mutual of Omaha Designation of Beneficiary Form

Interactive form 

Mutual Of Omaha Life Insurance Portability Request Form

Interactive form used to continue term life insurance within 60 days of employee's termination.

Status Change Form

Interactive form used to add/enroll dependent(s) and/or change participation levels (Restrictions Apply).

Supplemental Deletion Form

 Interactive form utilized for cancellation of supplemental insurance.

Vision - Humana CompBenefits Out of Network Reimbursement Form

Interactive form utilized for reimbursement of Out-of-Network Vision Care Claims