Benefits & Leave Forms
Below you will find commonly used Insurance, Retirement and Flexible Spending Account Forms. In addition, there may be times that you have to obtain forms directly from some benefit vendors. Here are links to certain vendor Web sites:
- NCFlex Benefit Plan Forms
- Teachers’ and State Employees’ Retirement System Forms
- State Health Plan of North Carolina
- Acknowledgement of Offer and Optional Waiver to Decline Coverage
- Affidavit For Domestic Partner
- Lincoln Financial Disability Evidence of Insurability Form
- Lincoln Financial Disability Claim Form
- Lincoln Financial Disability Enrollment Form
- The Standard Enrollment/Change Form
- The Standard Medical Statement Form
- MetLife Dental Domestic Partner Enrollment Form
Mandatory and supplemental retirement elections are managed electronically through ConnectCarolina. To enroll, terminate or submit changes to your mandatory and/or supplemental retirement plans:
- Log in to ConnectCarolina
- Choose Self Service from the drop-down menu at the top
- Choose the My Benefits tile
- Choose Benefits Enrollment on the left
- Select Mandatory Retirement Plan OR Supplemental Retirement Plans
- Attestation of In Loco Parentis Relationship
- COVID-19 Paid Administrative Leave (PAL) Request Form
- Creditable Service Form
- Employee’s Medical Certification, Form WH-380-E (Updated 7/20/20)
- Family & Medical Leave Request Form
- Families First Coronavirus Response Act (FFCRA) Request Form (Updated 8/1/20)
- Family Member’s Medical Certification, Form WH-380-F (Updated 7/20/20)
- Medical Leave Return To Work Form
- Military Caregiver for a Current Servicemember, Form WH-385
- Military Caregiver Leave for a Veteran, Form WH-385-V (Updated 7/20/20)
- Paid Parental Leave Request Form
- Qualifying Exigency, Form WH-384 (Updated 7/20/20)
- Voluntary Shared Leave (VSL) Donation Form
- Voluntary Shared Leave (VSL) Request Form
- Expanded CSL Request Form for Substitute School Service