Forms

NEISD

Employee Benefits

›NEISD

For New Hires and Family Status Changes Outside of Open Enrollment,
Click on the form needed, complete, print and send to Employee Benefits. *

*Open Enrollment changes must be made online during Open Enrollment
Open Enrollment-July 30--August 27, 2008

**All requests for changes to benefits must be received within 31 calendar days of the qualifying event. In the event that the 31st day falls on a weekend
or holiday, (including closed business days), requests must be received on the last working day prior to your 31st day.

Cancellation Form-Life, Disability, Cancer, and Vision

To cancel benefits that are not on the Cafeteria Plan (pre-taxed)

Cancer Insurance	When to use
Cancer Enrollment Application	New Enrollment or change in coverage
Wellness Claim Form	Filing a wellness claim for exam performed
Claim Form	Filing cancer/specified disease/ICU/Heart/Stroke Claims

Catastrophic Sick Leave Bank	When to use	Dental Plan	When to use
Sick Leave Bank Enrollment Form	Enrollment form to join the Sick Leave Bank.	Dental Enrollment/Change Form **For New Hires and Family Status Changes Only	New enrollees, add, cancel dependents. If premium is on the Cafeteria Plan, complete the Cafeteria Plan Election Change form also.
Sick Leave Bank Physician's Statement	Complete page 1, Application for days must accompany Physician's statement.	Cafeteria Plan Election Form **For New Hires	Use this form to have your premiums either pre-tax or taxable.
Sick Leave Bank Application - Sick Days	Complete page 1, Physicians Statement must accompany Sick Leave Bank Application for days.	Cafeteria Plan Election Change **For Family Status Changes only	Complete this form to make changes to your benefit selections already on the Cafeteria plan when you experience a family status change outside of the Open Enrollment period.
		Dependent Certification	To continue coverage beyond the max age limit (19-24), this form must be rec'd within 31 days of the affected dependent becoming eligible.

Disability Plan	When to use	Hospital Indemnity	When to use
Application for Coverage.	New Employee Enrollment form (within first 60 days of employment).	Hospital Indemnity Claim Form	$250 per day reimbursement for inpatient hospital confinement.
Disability Claim Form	For employees who wish to make a benefit claim

Incentive Program	When to use	Life/Survivor Benefits	When to use
MetLife 401(a) change form	This form is to be used by current participants only. For personal information changes.	American Natl - Enrollment Form	Life Insurance enrollment form. Evidence of Insurability must be completed (page 2).
MetLife 401(a) Participation form	Participation Agreement for new and existing participants	American Natl - Change Form	Beneficiary and Name changes.
MetLife Beneficiary Designation-401(a)	Beneficiary changes for participants	Designation of Beneficiary - TRS	Updates TRS beneficiary only.
		$10,000 Life Insurance Beneficiary Change Form	Designation of beneficiary for the $10,000 life insurance.

Medical	When to use	Section 125 (cafeteria/FSA)	When to use
Health Insurance Enrollment Form	New Enrollment or Change in Health Coverage. Complete the Cafeteria Plan Election Change Form if you elect to have your premium on the Cafeteria Plan.	Cafeteria Plan Election Form	Use this form to have your premiums either pre/post-taxed.
Cafeteria Plan Election Form	Use this form to have your premiums either pre/post taxed.	Cafeteria Plan Election Change	Complete this form to make changes to your benefit selections when you experience a family status change outside of the Open Enrollment period.
Cafeteria Plan Election Change	Complete this form to make changes to your benefit selections when you experience a family status change outside of the Open Enrollment period.	Flexible Spending Change Forms	For Family Status Changes to your FSA account.
Dependent Certification	To continue coverage beyond the max age limit (19-24)this form must be rec'd within 31 days of the affected dependent becoming eligible.	Flexible Spending Enrollment Form	For new enrollments and Family Status Changes.
Prescription Reimbursement Claim Form	Members with pharmacy benefits through BC/BS can use this form to file pharmacy claims for reimbursement. This form is to be used for those participants who have not received a membership card and must pay out of pocket.
Mail Order Prescription Form	Order your prescriptions through our mail order program

Tax Sheltered Accounts	When to use	Vision Plan	When to use
Tax Sheltered Accounts (403b)	Salary Reduction Agreement & Disclaimer Statement - 403b, Tax Sheltered Annuity please call JEM at 1-800-943-9179 or go to www.jemtpa.com	Enrollment Form **For New Hires and Family Status Changes only.	New Enrollment or Change in Coverage. Complete the Cafeteria Plan Election Change Form if you elect to have your premium on the Cafeteria Plan.
MetLife 457(b) change form	This form is to be used by current participants only. For personal information changes.	Cafeteria Plan Election Form	Use this form to have your premiums either pre-tax or taxable.
MetLife 401(a) change form	This form is to be used by current participants only. For personal information changes.	Cafeteria Plan Election Change **For Family Status Changes only	Complete this form to make changes to your benefit selections already on the Cafeteria plan when you experience a family status change outside of the Open Enrollment period.
MetLife 457(b) beneficiary change form	Beneficiary changes for participants	Dependent Certification	To continue coverage beyond the max age limit, (19-24), this form must be rec'd within 31 days of the affected dependent becoming eligible.