COBRA Rates July 1, 2012 – June 30, 2013
COBRA Rates July 1, 2011 - June 30, 2012
COBRA Rates July 1, 2010 - June 30, 2011
COBRA Initial Notice
This explains the eligibility requirements to be enrolled in COBRA.
Important Notice About Your Health Care Benefits Upon Separation
Delta Dental of Ohio Claim Form
NOTE: If you seek treatment from a participating dentist, you do not need to print a claim form; the dentist will have a form and will submit it for you.
Benefit Enrollment and Change Form (ADM 4717) (exempts) (For use effective July 1, 2013.)
When you and your dependents become eligible for dental or vision coverage, complete this form and return it to your payroll office. See the Dental and Vision pages for more information.
Application for Disability Leave Benefits-Employee Statement (ADM 4310)
This form is used only for an initial filing of benefits.
Application for Disability Leave Benefits-Employer Statement (ADM 4312)
This is the employer's information and is to be attached to ADM 4310. This form is also used when the employee is requesting an extension of benefits.
Disability Agreement (ADM 4313)
This form is used when filing for disability as an advancement of Workers' Compensation.
Disability - Agency Disability Questionnaire
This form is to be completed by the employer and should accompany all initial mental health-related disability claims being filed with DAS-Benefits Administrative Services-Disability.
Disability - Request for Appeal
Statement of Psychiatric Disability (ADM 4316)
This form is to be used when filing for disability benefits for mental/behavioral health disability. This should be used in addition to ADM 4310.
Supplemental Report for Disability Leave -Employee Statement (ADM 4311)
This form is to be used by the employee to request an extension of disability benefits.
Supplemental Report for Disability Leave-Employer Statement
This form is to be completed by the agency and accompany the employee's Supplement Report for disability leave benefits being submitted to BAS.
Work Capacity Form (ADM 4317)
This form is to be completed by the attending physician for use in transitional return to work. This may be used for either Worker's Compensation or Disability.
Affidavit of House Bill 1 Child Status (Beginning July 1, 2013)
Affidavit of House Bill 1 Child Status (Before July 1, 2013)
Definitions and Required Documents Checklist
Use this checklist to see documents required to enroll a dependent for the 2011 Benefits Open Enrollment.
Required Documents for Dropping Dependents Checklist
Use this checklist to see documents required to disenroll a dependent.
Verification Form (for union dental/vision benefits only)
Affidavit of Common Law Marriage (ADM 4731)
This affidavit should be used to enroll a common law spouse for benefits.
Affidavit of Student Status (ADM 4729)
This affidavit is to be completed when an enrolled dependent turns 19, a dependent is being enrolled in coverage, or the document is requested during the course of an audit.
Medical Mutual of Ohio(Ohio Med) Handicap Child Member Form
Medical Mutual of Ohio (Ohio Med) enrollees who have a handicapped dependent child who is 1.) between the ages of 19 and 23 and not a student, or 2.) over the age of 23 must complete this form and send it to Medical Mutual of Ohio (Ohio Med) per instructions on the form.
United Health Care
United Healthcare Handicap Child Member Form
United Healthcare enrollees who have a handicapped dependent child who is 1.) between the ages of 19 and 23 and not a student, or 2.) over the age of 23 must complete this form and send it to United Healthcare per instructions on the form.
Life Insurance (Basic) Beneficiary Designation/Change Form (SI 11210-645571)
The Standard Insurance Company's fillable beneficiary form for exempt employees. Can be completed online, printed, signed and then mailed to The Standard Insurance Company at the address on the form.
Life Insurance (Basic) Continuation Form (ADM 4302) (for laid-off employees)
Life Insurance (Supplemental) Conversion Privilege Form (for exempts)
Exempt employees may use this form to convert their supplemental (employee-paid) term insurance to whole life insurance upon leaving active state employment.
Life Insurance (Supplemental) Enrollment and Beneficiary Designation Form (for exempts)
Union-represented employees should consult the Union Benefits Trust at 800-228-5088 for information. Click here for detailed information about using this form.
Life Insurance, The Standard Insurance Claim Form (for exempts)
This form should be used by beneficiaries to apply for benefits upon the death of a covered exempt State employee.
Life Insurance, The Standard Insurance Dismemberment Claim Form (for exempts)
This form should be used by exempt employees to file a work-related claim for loss of a limb, hearing or sight.
Life Insurance, The Standard Accelerated Benefit Application (for exempts)
This form may be used by exempt employees to apply for an advancement of benefits if diagnosed with a terminal illness.
Life Insurance, The Standard Insurance Application for Portability (for exempts)
This form should be used by exempt employees to apply for a continuation of their life insurance after leaving State employment.
Benefit Enrollment and Change Form (ADM 4717) (For use effective July 1, 2013.)
Needed to initially enroll yourself and your dependents in the Ohio Med PPO. Also used to make changes throughout the year such as the addition of a newborn or adopted child, the removal of a dependent, changing from family to single coverage, etc. For more information, see the Pathways to myBenefits spring publication.
Catamaran Mail Order Registration & Prescription Order Form
Use this form to register to use the Catamaran mail order program provided by Catamaran Home Delivery.
Catamaran Direct Member Reimbursement Form
Use this form to request reimbursement from Catamaran for unpaid prescription drug claims.
Catamaran Prescription Fax Form
The Prescription Fax Form is a form that you can take to your physician's office during an office visit to have your physician fax your prescription to our mail service provider Catamaran Home Delivery. This form must be faxed directly from your physician's office in order to be valid.
Child Care Voucher Application
Flexible Spending Account materials
2014 Reference Guide
Health Care Spending Account:
2014 Flexible Spending Account Health Care Spending Account Enrollment Form
2014 Flexible Spending Account Health Care Claim Form
2014 Flexible Spending Account Health Care Spending Account Worksheet
Dependent Care Spending Account:
2014 Flexible Spending Account Dependent Care Spending Account Enrollment Form
2014 Flexible Spending Account Dependent Care Claim Form
2014 Flexible Spending Account Dependent Care Spending Account Worksheet
Click here to return to the Flexible Spending Account web page.
Accident or Illness Report (ADM 4303)
This report should be completed if you are injured at work. For more details, see the Workers' Compensation Web page.
Salary Continuation or Occupational Injury Leave Extension Request Form (ADM 4726)
Calendar of Wages Paid (ADM 4741)
This form is for agency use only. This form is used by the agency to report wages for lost time Workers' Compensation claims.
SC or OIL Reactivation Request Form (ADM 4722)
SC/OIL Hourly Payment Request Form
This form is to be used by an employee when requesting the use of SC/OIL on an hourly basis. This form is to be used only if the employee is in a transitional work program.
SC and OIL Appeal Form
Part-time Employment Calculation Report (ADM 4728)