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Category: Forms

Express Scripts COB Form

Complete this form to submit a claim to for pharmacy purchases. Express Scripts Rx Reimbursement and Coordination of Benefits Claim Form

Schedule A Agreement

Career Service Exempt Conversion Election Agreement & Acknowledgement Career Service Exempt Appointments   

Express Scripts by Mail

Complete this form to submit a prescription by mail to Express Scripts to the address listed on the claim form. Express Scripts by Mail form

PEHP Healthy Utah and Wellness Rebates

For the most recent PEHP Healthy Utah “Know and Plan”, “Good for You” and other wellness rebate forms, please click on the link below to be directed to the Healthy Utah Forms section of the PEHP web site.  You will not be required to log in to access these forms. Healthy Utah Forms

Abusive Conduct Intake Form

This form is for the purpose of reporting Abusive Conduct, consistent with DHRM Rule R477-16. If you would like to make a complaint of Unlawful Workplace Harassment, as described in DHRM Rule R477-15, please contact your HR Specialist. Abusive Conduct Intake Form

Classification Position Analysis Form – PAF

All information on the PAF (Position Analysis Form) should be completed by the incumbent and/or supervisor to reflect the tasks currently assigned to the position.  Please refer to the Classification Review Request (CRR-3) form to initiate a request for a preliminary classification review of an incumbent filled position(s). Position Analysis Form PAF Revised 10.9.14

Savings Plans Direct Deposit for One-time Payments

Use this form for a direct deposit of one-time payments from your Utah Retirement Systems (URS) Savings Plans (401(k), 457, and IRAs). Completed forms can be sent directly to URS at fax number 801-366-7445. URS Savings Plans Direct Deposit for One-time Payments

Uncompensated Overtime Claim Form for Non-Exempt Employees

This form is used by State of Utah employees who desire to make a claim to be compensated for overtime hours for which they were required or permitted to work, over the past three years up to today’s date, but for which they were not compensated due to the work hours not being recorded on their previously submitted time sheets or electronic records (ESS). Uncompensated Overtime Claim Form 2014

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