FORMS

Forms

Welcome to the forms section!  Here you will find the most commonly used forms for the benefit plans offered at JFS.  If you still cannot find what you need after reviewing this section, please contact the Benefits Helpline for assistance.

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Medical Plan Forms

Kaiser Permanente WA Enrollment Form

Health Plan Waiver Form

Principal - Dental, Life and Disability Enrollment Kit with Forms

Principal Dental, Life and Disability Enrollment Form

Vision Plan Forms

VSP Enrollment Form

Flexible Spending Plan Forms

 

Flexible Spending Plan Enrollment Form

Flexible Spending Plan Claim Form

Transit Enrollment Form

Transit Plan Claim Form

 

Life and Disability Forms

Life and Disability Enrollment and Beneficiary Form

Life Insurance Evidence of Insurability Form

Life Insurance Claim Form

Life Insurance Portability and Conversion Form

Long-Term Disability Claim Form

Voluntary Life Rates

 

Health Reimbursement Arrangement Online Form Summary

Health Reimbursement Arrangement Summary

PacificSource offers several ways you can submit your claims for reimbursement:
1. Submit your claim online using our PSAConsumer portal: https://psa.consumer.pacificsource.com
2. Submit your claim via our Mobile App: myPacificSource Admin (PSA)
3. Mail or fax a Request for Reimbursement Form. You’ll find the form at PSA.PacificSource.com/ Forms_Flex.aspx