Employee Benefit Forms

Please print a copy and forward the completed signed original to the Employee Benefit’s Office for processing.  Be sure to make a copy for your records.

Appeal - Complete this form when you disagree with the way a claim was processed, the denial of a claim in whole or part, or the way benefits were applied. Your request must be made within 60 days after the date the claim was processed. 

Appointment of Personal Representative  - Under the new privacy regulations, the City of Mesa Plan, which is administered by the Employee Benefits Office, cannot disclose your protected health information (PHI) to another person without your authorization. This form needs to be completed by the plan member, his/her spouse, and/or dependent children over age 18 and returned to the Benefits Office. 

Revocation of Personal Representative - Complete this form if you need to remove your current appointed Personal Representative.  To designate a new appointee, complete the Appointment of Personal Representative form above and send both forms to Employee Benefits.

Benefit Enrollment/Change Form - Complete this form when adding new dependents, dropping ineligible dependents, or to change life insurance beneficiary. When adding new dependents or dropping ineligible dependents, please submit this form to Employee Benefits within 31 days from date of qualifying event (i.e., date of birth, date of marriage, child turns 19 and is not a full-time student). 

Flexible Spending Account (FSA) Health Care Claim OR FSA Dependent Care Claim 
Use the Health Care or Dependent Care Claim Forms to request reimbursement of benefits under your health care or dependent care flexible spending account.  The Dependent Care Claim Form is used for day care expenses only. 

HIPAA Privacy Notice - Required by the new federal privacy law, The Health Insurance Portability and Accountability Act (HIPAA) of 1996, all employees and retirees must receive a Privacy Notice. This notice describes how medical information about you may be used and disclosed and how you may obtain access to this information.

Short Term Disability Enrollment/Change Form  - Complete this form when applying for or making changes to your Short Term Disability coverage. During Open Enrollment, you can enroll online instead of using this paper form. (This form is combined with the Supplemental Life Insurance Enrollment/Change Form.)

Short-Term Disability Claim Form - Full-time employees that have elected to participate in the voluntary shot term disability program can submit this form when they cannot work due to an accident, illness, or pregnancy. You should submit this form as soon as you know you are going to be out on STD leave.  

Student Status - Complete this form when you have any dependent ages 19 to 22, that is a full-time student, and you want to continue active coverage on. We require a copy of their current registration showing their name, the name of accredited institute of learning, and enrollment in at least 12 credit hours. This documentation is required each semester.

Supplemental Life Insurance Enrollment/Change Form - Complete this form when applying for or increasing Supplemental Life Insurance. (You can also enroll online during Open Enrollment instead of using this paper form.)  Whether applying online or on paper, the Evidence of Insurability Form must be completed and submitted to Employee Benefits. (See form link below.) This form is combined with the Short Term Disability Enrollment/Change Form.

• Evidence of Insurability Form (Medical History Form) - This form MUST be printed and completed if you are enrolling in or increasing the Supplemental Life Insurance. Submit this form to Employee Benefits.  If you are enrolling your spouse or increasing your spouse's coverage, complete the Evidence of Insurability form for your spouse.  Signatures are required from both the employee and the spouse. 

Sure Pay - Retirees can complete this form to have the convenient option of having their insurance premiums automatically deducted from their checking account on a monthly basis.