Forms
The following forms must be signed via Docusign only. Please contact our office for access:
- Certification of Financial Dependency of Grandchildren
- Direct Debit Authorization Agreement
- Harris County Retiree Health & Related Benefits Change Form
- Health and Related Benefits Waiver- Retirees
- Health and Related Benefits Waiver- Active Employees
- Insurance Deduction Authorization for Public Safety Officers
- Retiree Life Insurance Beneficiary Update Form
Plan and Legal Documents
EVICORE ADVANCED RADIOLOGY FACILITIES
GROUP LONG TERM DISABILITY CERTIFICATE
MODEL NOTICE FOR EMPLOYERS WHO OFFER A HEALTH PLAN TO SOME OR ALL EMPLOYEES
MODEL NOTICE FOR EMPLOYERS WHO OFFER A HEALTH PLAN TO SOME OR ALL EMPLOYEES - SPANISH VERSION
SUMMARY OF BENEFITS - BASE PLAN
SUMMARY OF BENEFITS - BASE HAMP PLAN
SUMMARY OF BENEFITS - PLUS PLAN
SUMMARY OF BENEFITS - PLUS HAMP PLAN
SUMMARY OF BENEFITS AND COVERAGE - BASE PLAN
SUMMARY OF BENEFITS AND COVERAGE - BASE HAMP PLAN
SUMMARY OF BENEFITS AND COVERAGE - PLUS PLAN
SUMMARY OF BENEFITS AND COVERAGE - PLUS HAMP PLAN
SUMMARY PLAN DESCRIPTION - BASE PLAN
SUMMARY PLAN DESCRIPTION - BASE HAMP PLAN
SUMMARY PLAN DESCRIPTION - BASE RETIREE PLAN
SUMMARY PLAN DESCRIPTION - PLUS PLAN
SUMMARY PLAN DESCRIPTION - PLUS HAMP PLAN
SUMMARY PLAN DESCRIPTION - PLUS RETIREE PLAN