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Human Resources - Forms Library

Benefits Summary

• Summary Plan Description

• Health Benefits Summary - Option 1

• Health Benefits Summary - Option 2

• Health Benefits Summary - Option 3

• Dental Benefits Summary - Option 1

• Dental Benefits Summary - Option 2

Benefits Forms

• Request a Medical or Dental Card Replacement

• Donated Leave Packet

• Educational & Longevity Pay Table

• Employee Clinic Forms

• Educational Assistance Packet

• Insurance Contact List

• Leave Request Form

Dental

• Claim Form

Flexible Spending Account

• Claim Form

• AFLAC Flexible Spending Reimbursement Form

• Eligible and Ineligible Expenses

Life

• Beneficiary Change Form

Medical

• Medical Insurance Termination Form

• Medical Insurance Change Form

• Medical Claims Appeal Procedures

Retirement

• PERS Member Handbook

• PERS Change of Beneficiary Form

• PERS Change of Information Form

Tax

• State Withholding Form

• 2010 W4 Federal Tax Form

All Other Forms

• 2010 Employee Attendance Calendar

• 2010 Phone List

• Annual Leave Accrual

• Direct Deposit Enrollment/Change Form

• Employee Change of Information/Address Packet

• Employee Counseling Form

• Employee Requisition

• GEM Nomination Form

• Release of Information Authorization Form

• Personnel Action Notice (PAN)

• Personnel Policies & Procedures Manual

• Transfer Request

• Workman’s Compensation Packet

City of Gulfport, Mississippi - Office of the Mayor
P.O. Box 1780 | Gulfport, MS 39502 | (228) 868-5700