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Benefit Forms

For your convenience, the forms listed below can be completed online and then printed.  Unless noted, the forms should be submitted directly to the Human Resources and Risk Management (HRRM) Department.  If you have any questions on completing the forms, please contact HRRM at 425.430.7650.  Use the table of contents below and click on the link to be directed to additional information about that particular category of forms:

          MEDICAL FORMS

          BENEFICIARY CHANGES 

          DEFERRED COMPENSATION

          FLEXIBLE BENEFITS

          FAMILY MEDICAL LEAVE ACT (FMLA)

          LEAVE DONATION

          W-4 FORM

          ADDRESS/INFORMATION CHANGE

 


Medical Forms

These forms should be used to add or delete dependents to your healthcare plan.  If you get married, your spouse should be added within 31 days of the event.  To add a newborn or newly adopted child, the child should be added within 60 days from the date of birth or placement for adoption.

Prescription Forms

The Pharmacy Benefit Manager for the City's healthcare plan is EnvisionRx.  Prescription mail order service is provided through Costco Mail Order Pharmacy. 

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Beneficiary Changes

You can make beneficiary changes for the following benefits at any time.  Complete and submit to HRRM.

 

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Deferred Compensation

TIAA-CREF

  •  Contribution Change Form To increase, decrease, suspend or resume your contributions to TIAA-CREF, please complete and    submit this form to HRRM.

  • You can change your investment election, contact information, or beneficiary information by visiting the  TIAA-CREF Website.


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Flexible Benefits

You must have enrolled during open enrollment each year or upon employment as a regular employee. 

 

  • Request for Reimbursement Health Care Claim Form:  Submit this form to Benefit Administration Company, which administers the 125 Flexible Spending for the City of Renton.  You may submit the forms to Benefit Administration at any time as you incur eligible expenses during the calendar year.  The deadline to submit forms for previous year expenses is March 31.

  • Request for Reimbursement Dependent Care Claim Form:  Submit this form to Benefit Administration Company, which administers the 125 Flexible Spending for the City of Renton.  You may submit the forms to Benefit Administration at any time as you incur eligible expenses during the calendar year.  The deadline to submit forms for previous year expenses is March 31.

  • Authorization Agreement for Direct Deposits:  Provides authorization for the Benefit Administration Company to initiate 125 Flexible Benefit deposits to your bank account.  


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Family Medical Leave Act (FMLA)

An eligible employee with a qualifying event requesting FMLA leave is required to provide 30 days notice for events that are foreseeable.  If it is not possible to give 30 days notice, the employee must give notice as soon as possible.  For more information, you may click here to access Policy #350-03, Family Medical Leave Act and Washington State Family Care Act.  FMLA guidelines require the following forms be submitted to HRRM.


Forms Required to Request FMLA For Employee’s Own Serious Health Condition:


Forms Required to Request FMLA For Employee’s Family Member'S Serious Health Condition:


Forms Required to Request FMLA for Military Family Leave Entitlements:


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Leave Donation

 


W-4 Form

  • W-4 Form:  Complete and submit this form to Payroll to change the number of allowances or exemptions from withholding on your W-4. 

  • To assist you to determine how much you would like withheld, you can utilize the W-4 Calculator located on the Internal Revenue Service website:  IRS W-4 Calculator


Address/Information Change

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