Benefits Forms
REMEMBER: Enrollment in medical, dental, optional life, and long-term disability insurnance, and flexible spending accounts, can only be completed through online enrollment. These forms pertain to specific instances in which a form must be filled out separately from the online benefits administration system. See "More Benefits Information" below to access the State's online Benefits Administration System (BAS).
Affidavits
Same-Gender Domestic Partnership
Termination of Same-Gender Domestic Partnership
- Information for Same-Gender Domestic Partners (SGDPs) - SGDPs are eligible for State medical, dental, and optional life insurance coverage as the partner of a State employee.
Benefits Appeals
Employee Benefits Appeal Form - To appeal an eligibility determination for State of Colorado plans; NOT to be used to appeal claims, such as a determination by an insurance company of what is and is not covered.
Dental Insurance
Disability Insurance - Short-Term (STD) & Long-Term (LTD)
Medical History Statement for LTD - Standard Insurance
Standard Insurance Short-Term Disability Claim Form
Flexible Spending Accounts
FSA Claim Form - On the next page, click on "Forms," then "Claim Forms," then find the form specifically for State of Colorado employees.
Direct Deposit / E-mail Notification Authorization Form - On the next page, click on "Forms."
Medical Insurance
Kaiser Permanente Forms
Application for Disabled Dependent
UnitedHealthcare Forms
UnitedHealthcare Medical Claim Form
UnitedHealthcare Disabled Adult Dependent Statement - To be completed by the employee and the physician, then sent to UnitedHealthcare
UnitedHealthcare Mail-Service Prescription Order Form - Must be mailed, along with original prescription, to address on form.
Retirement
PERA Choice & Forms
More Benefits Information
HealthLine - The Employee Benefits Newsletter
Insurance Premiums
Enroll/Change Your Benefits - link to State's online Benefits Administration System (BAS)
Your department's HR/Benefits personnel
Instructions for Online Enrollment
What do "Pre-tax" and "After-tax" mean?
Glossary of Insurance Terms
Forms
Salary Reduction Plan
For Employee Benefits contacts: DPA Benefits Unit.
Email comments to: DPA Benefits