Privacy & Security Notice    

     

Forms For Active Employees

 

      
                Welcome to the Forms page for Active Participants.  Select the appropriate form from the table below.  The forms are listed in alphabetical order.  After READING ALL INSTRUCTIONS, fill out the form, and return it to the appropriate party.
       

Employees

    

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  EMPLOYEE PLAN INFO   RETIREE PLAN INFO   PENSION/SAVINGS INFO
 
 
  Form Name / Description
  BENEFICIARY DESIGNATION FORM - If you are updating this form as a result of a life event (marriage, death, divorce, etc.) please contact and notify benefits administration via email at *Benefits.  PLEASE READ THE INSTRUCTIONS PRIOR TO FILLING OUT THE FORM!
  BENEFICIARY DESIGNATION FORM INSTRUCTIONS
  FLEXIBLE SPENDING ACCOUNT (FSA) CLAIM FORM - Fill out this form if you would like to make a withdrawl request.
  FLEXIBLE SPENDING ACCOUNT CLAIM FORM - INSTRUCTIONS - Instructions for filling out the FSA Form
  GROUP DENTAL CLAIM FORM - Fill out this form for dental claims under the Dental Assistance or Dental Plus plans.
  UnitedHealthcare Vision OutofNetwork Claim Form - Fill out this form for claims associated with a Spectera Vision plan.
  UNITEDHEALTHCARE CLAIM FORM - Medical claim form for participants of UnitedHealthcare plans.
  W2 REQUEST FORM - This form must completed to process a request for your W2.
  W4 FORM - Fill out this form if you would like to change your W4 information.
     

Send questions or comments to: mailto:benefits_-_PHMC@rl.gov
 
 
 
 
 
 
 
 
 

Retirees

  
 
 
 
 
 

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