Employee Forms
- Enrollment Form - This MUST be signed and turned in to Payroll/Benefits office before separation/retirement.
- Spouse Dependent Information - This Must be signed and turned into Payroll/Benefits office before sparation/retirement.
- Claim Form - Use for reimbursement of medical expenses. Follow instructions on form.
- Election of Limited Montana VEBA HRA plan Coverage Form - Allows members who participate in a High Deductible Health Plan (HDHP) and a Health Savings Account (HSA) is utilized for contributions. This allows you to limit your VEBA account reimbursements to only the allowable expenses (Dental, Orthodontia, and Vision expenses). This limitation on the VEBA account will continue until such time as you are no longer on the HDHP and there are funds being contributed to the HSA account. All eligible members of the family will need to limit their reimbursement from the VEBA plan to the same dental and vision expenses until the HDHP coverage is no longer in place.
- Direct Deposit Enrollment Form - Fill out and mail to have your reimbursements go directly to your checking account.
- Account Fund Allocation Form - Allows you to change your fund allocations (up to monthly) for the 9 Investment Fund Options.
- Systematic Payment Form - Allows you to set up payment options for your Medical Premiums.
- Declaration of Tax Status of Domestic Partner - If applicable, fill in and mail as instructed on form.
- Qualified Expenses and Premiums
- COBRA Forms - If applicable, fill in and mail as instructed on form
Please return all forms to Health Care and Benefits Division PO Box 200130 Helena, MT 59620-0130
