2011 Forms

• 2011 Active Employee Enrollment -Change Application (PDF - 90.4 KB)
  
  
• KEHP Retirees Enrollment -Change Application (PDF - 97 KB)
  
  
• KEHP Flexible Spending Accounts Application  (PDF - 90.4 KB)
  
  
• 2011 KEHP Update Form (PDF - 54 KB)
  
  
• Dependent Eligibility Rules and Verification Requirements 
  (PDF - 54 KB)
  
  
• 2011 Certification of Dependent Eligibility (PDF - 67 KB)
  
  
• FSA and HRA Reimbursement Form (PDF - 124 KB)
  
  
• FSA Qualifying Event Change Form  (PDF - 68 KB)
  
  
• FSA/HRA Refund Request Form 2011 (PDF - 73 KB)

• Non Smoker Affidavit 2011(PDF - 33KB)
  
  
• Post Tax Request Form 2011(PDF - 54KB)
  
  
• Pre-Tax Form 2011(PDF - 66KB)
  
  
• Authorization for Release of Information (PDF - 26 KB)
  
  
• Admin Fee Refund Request (XLS - 30.5KB)
  
  
• Premium Refund Request (XLS - 33.5KB)
  
  
• Request for Access to KHRIS Form (PDF - 252KB)
  
  
• Transmittal Log (PDF - 10 KB)
  
  
• KHRIS Credit Request Form(PDF - 38KB)
  
  
• Medicaid Eligibility/Termination Form and Instructions (PDF -  40 KB)