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Benefit Forms
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Accidental Death & Dismemberment Form
Complete this form to enroll in or make changes to the Accidental Death & Dismemberment optional plan offered by ...
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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 ...
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Express Scripts COB Form
Complete this form to submit a claim to for pharmacy purchases. Express Scripts Rx Reimbursement and Coordination of ...
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FI11 Leave Donation Form
Complete this form to donate Annual, Converted Sick or Excess hours to your agency’s leave bank or to a specific ...
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Flexible Spending Account (FSA) Claim Form
Complete this form to submit eligible expenses for reimbursement from your Flexible Spending Account (FSA). This form and ...
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Flexible Spending Account (FSA) Enrollment Form
Complete this form to enroll in a Flexible Reimbursement Account. Flex Enrollment Form OR Online Flex Enrollment (Once ...
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FMLA Application
Complete this form and submit to your local Human Resource Office HR Specialist. During the application process and FMLA ...
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FMLA Certification – Serious Illness or Injury of Service Member
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave due to a ...
- FMLA Certification Form for a Family Member The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because ...
- FMLA Certification Form for Employees The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because ...
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FMLA Certification Form for Qualifying Exigency for Military Leave
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave due to a ...
- FMLA Designation Notice – Form 382
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FMLA Employee Rights & Responsibilities
This fact sheet provided information related to an employee’s rights and responsibilities under the Family and Medical ...
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FMLA Fact Sheet
This Fact Sheet provides answers to some common questions employees have about FMLA leave. All FMLA leave must be ...
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FMLA Fitness for Duty Certification – Return to Work Release
Employees using FMLA leave are required to provide this fitness for duty certification and intent to return to work to the ...
- FMLA Notice of Eligibility – Form 381
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FMLA Roles & Responsibilities for Supervisors
This fact sheet assists supervisors with understanding their rights and responsibilities when they have an employee who is ...
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HSA Election Form
If you participate in a High Deductible STAR Plan you have the option to contribute to an Health Spending (HSA) account and ...
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Hyatt Legal Bulletin
Hyatt Legal is optional insurance offered to employees. It offers a solution to most of your legal needs. Telephonic ...
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Life Insurance Enrollment and Change Forms
All benefits eligible employees must complete these forms to designate beneficiaries for the basic coverage funded by the ...
- Life Insurance Enrollment and Change Forms for EXEMPT Employees Complete these forms to enroll in Life Insurance if you are in an appointed, elected or other eligible positions designated ...
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Life Insurance Enrollment Form for Spouse/Dependents
To enroll your spouse and/or dependents in the Life Insurance Plan PEHP offers complete this form and submit to PEHP ...
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Military Leave Worksheet
This form is for employees who will be out on Military Leave (after 15 days of Military Leave has been exhausted). The ...
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One Time & Irrevocable Pre-2006 Transfer Request
As of January 1, 2011, an employee who is participating in the Unused Sick Leave Retirement Program I under Section ...
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PEHP Disclosure Authorization
Complete this form to authorize disclosure of medical information to Group Time Life Program. HIPAA Disclosure Authorization ...
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PEHP Exiting Employment Form
This form is to be completed by a Human Resource representative and provided to an employee either in person or via mail ...
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PEHP Healthy Utah and Wellness Rebates
For the most recent PEHP Healthy Utah “Know and Plan”, “Good for You” and other wellness rebate ...
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PEHP Leave Worksheet
This form is to be completed for employees who will be out on FMLA, Leave Without Pay / Unpaid leave or for Workers Comp ...
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PEHP Medical, Dental and Vision Form
Complete this form to either enroll or update your PEHP Medical, Dental and Vision coverages. The form should be sent to ...
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Post (After) Retirement Employment Form
Complete this form when you are rehired retiree to acknowledge you have read the Explanation of Post Retirement Employment ...
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Program I (Pre-2006) & Program II (Pre-2014) Sick & Converted Sick Leave Transfer Request
Complete this form to request a transfer of Program I (Pre-2006) and/or Program II (Pre-2014) Sick or Converted Sick to ...
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Request of Payment of Leave for LTD Approved Employees
This form is for employees who are approved for LTD only. Use this form to indicate when you would like any eligible leave ...
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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, ...
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Short Term Disability Enrollment/Change Form
Enrollment and changes to short term disability must be completed online only here Please DO NOT USE the following form ...
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Tier I DB Opt Out Form
Complete this form to opt out of defined benefit coverage. Completed forms can be sent directly to Utah Retirement Systems ...
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URS 401k or 457 Enrollment Contract
Complete this form to enroll in either a 401(k) or 457 plan.
URS Enrollment Contract for 401k or 457 Plan
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URS 401k Withdrawal/Rollover Form
Complete this form to either rollover funds from a previous employer or to withdraw funds from your URS 401(k) account if ...
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URS 457 Withdrawal/Rollover Form
Complete this form to rollover eligible funds to your URS 457 account or to withdraw funds upon leaving state ...
- URS Beneficiary Designation Form Complete this form to designate or update beneficiary information with Utah Retirement Systems, completed forms may be faxed ...
- URS Eligibility Certification Form This form notifies Utah Retirement Systems an employee is eligible for retirement benefits. An authorized signature is ...
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URS Employee Benefits Notification (ADNT-2)
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URS Employee Separation Notice – ADNT-3
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URS Investment Contract for 401k or 457 Plan
Complete this form to make changes to your 401k or 457 plan or to notify Utah Retirement systems you no longer want to ...
- URS Leave Notification Form This form notifies URS when an employee is out on Leave Without Pay status so retirement benefits can be adjusted as ...
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URS Statement of Ineligibility
This form notifies URS when an employee is not eligible for retirement benefits and also notifies the employee they can ...
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URS Tier I Request for Exemption
This form is to be completed for position that are exempt from service credit accrual.
URS Tier 1 Request for Exemption
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URS Tier II Request for Exemption Form
Complete this form to opt out of Tier II defined contribution vesting. Completed forms can be sent directly to Utah ...
Family and Medical Leave Act (FMLA) Forms
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FMLA Application
Complete this form and submit to your local Human Resource Office HR Specialist. During the application process and FMLA ...
-
FMLA Certification – Serious Illness or Injury of Service Member
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave due to a ...
- FMLA Certification Form for a Family Member The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because ...
- FMLA Certification Form for Employees The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because ...
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FMLA Certification Form for Qualifying Exigency for Military Leave
The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA leave due to a ...
- FMLA Designation Notice – Form 382
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FMLA Employee Rights & Responsibilities
This fact sheet provided information related to an employee’s rights and responsibilities under the Family and Medical ...
-
FMLA Fact Sheet
This Fact Sheet provides answers to some common questions employees have about FMLA leave. All FMLA leave must be ...
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FMLA Fitness for Duty Certification – Return to Work Release
Employees using FMLA leave are required to provide this fitness for duty certification and intent to return to work to the ...
- FMLA Notice of Eligibility – Form 381
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FMLA Roles & Responsibilities for Supervisors
This fact sheet assists supervisors with understanding their rights and responsibilities when they have an employee who is ...
Flex and Health Savings Account Forms
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Flexible Spending Account (FSA) Claim Form
Complete this form to submit eligible expenses for reimbursement from your Flexible Spending Account (FSA). This form and ...
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Flexible Spending Account (FSA) Enrollment Form
Complete this form to enroll in a Flexible Reimbursement Account. Flex Enrollment Form OR Online Flex Enrollment (Once ...
Health and Wellness Forms
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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 ...
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Express Scripts COB Form
Complete this form to submit a claim to for pharmacy purchases. Express Scripts Rx Reimbursement and Coordination of ...
-
HSA Election Form
If you participate in a High Deductible STAR Plan you have the option to contribute to an Health Spending (HSA) account and ...
-
PEHP Exiting Employment Form
This form is to be completed by a Human Resource representative and provided to an employee either in person or via mail ...
-
PEHP Healthy Utah and Wellness Rebates
For the most recent PEHP Healthy Utah “Know and Plan”, “Good for You” and other wellness rebate ...
-
PEHP Leave Worksheet
This form is to be completed for employees who will be out on FMLA, Leave Without Pay / Unpaid leave or for Workers Comp ...
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PEHP Medical, Dental and Vision Form
Complete this form to either enroll or update your PEHP Medical, Dental and Vision coverages. The form should be sent to ...
Leave Forms
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FI11 Leave Donation Form
Complete this form to donate Annual, Converted Sick or Excess hours to your agency’s leave bank or to a specific ...
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Military Leave Worksheet
This form is for employees who will be out on Military Leave (after 15 days of Military Leave has been exhausted). The ...
-
One Time & Irrevocable Pre-2006 Transfer Request
As of January 1, 2011, an employee who is participating in the Unused Sick Leave Retirement Program I under Section ...
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Program I (Pre-2006) & Program II (Pre-2014) Sick & Converted Sick Leave Transfer Request
Complete this form to request a transfer of Program I (Pre-2006) and/or Program II (Pre-2014) Sick or Converted Sick to ...
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Request of Payment of Leave for LTD Approved Employees
This form is for employees who are approved for LTD only. Use this form to indicate when you would like any eligible leave ...
Life and Accident Policy Forms
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Accidental Death & Dismemberment Form
Complete this form to enroll in or make changes to the Accidental Death & Dismemberment optional plan offered by ...
-
Life Insurance Enrollment and Change Forms
All benefits eligible employees must complete these forms to designate beneficiaries for the basic coverage funded by the ...
- Life Insurance Enrollment and Change Forms for EXEMPT Employees Complete these forms to enroll in Life Insurance if you are in an appointed, elected or other eligible positions designated ...
-
Life Insurance Enrollment Form for Spouse/Dependents
To enroll your spouse and/or dependents in the Life Insurance Plan PEHP offers complete this form and submit to PEHP ...
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PEHP Disclosure Authorization
Complete this form to authorize disclosure of medical information to Group Time Life Program. HIPAA Disclosure Authorization ...
Retirement and 401k / 457 Plan Forms
-
Post (After) Retirement Employment Form
Complete this form when you are rehired retiree to acknowledge you have read the Explanation of Post Retirement Employment ...
-
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, ...
-
Tier I DB Opt Out Form
Complete this form to opt out of defined benefit coverage. Completed forms can be sent directly to Utah Retirement Systems ...
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URS 401k or 457 Enrollment Contract
Complete this form to enroll in either a 401(k) or 457 plan.
URS Enrollment Contract for 401k or 457 Plan
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URS 401k Withdrawal/Rollover Form
Complete this form to either rollover funds from a previous employer or to withdraw funds from your URS 401(k) account if ...
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URS 457 Withdrawal/Rollover Form
Complete this form to rollover eligible funds to your URS 457 account or to withdraw funds upon leaving state ...
- URS Beneficiary Designation Form Complete this form to designate or update beneficiary information with Utah Retirement Systems, completed forms may be faxed ...
- URS Eligibility Certification Form This form notifies Utah Retirement Systems an employee is eligible for retirement benefits. An authorized signature is ...
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URS Investment Contract for 401k or 457 Plan
Complete this form to make changes to your 401k or 457 plan or to notify Utah Retirement systems you no longer want to ...
- URS Leave Notification Form This form notifies URS when an employee is out on Leave Without Pay status so retirement benefits can be adjusted as ...
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URS Statement of Ineligibility
This form notifies URS when an employee is not eligible for retirement benefits and also notifies the employee they can ...
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URS Tier II Request for Exemption Form
Complete this form to opt out of Tier II defined contribution vesting. Completed forms can be sent directly to Utah ...
Voluntary Benefit Forms
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Hyatt Legal Bulletin
Hyatt Legal is optional insurance offered to employees. It offers a solution to most of your legal needs. Telephonic ...
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Short Term Disability Enrollment/Change Form
Enrollment and changes to short term disability must be completed online only here Please DO NOT USE the following form ...
Employment Forms
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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 ...
- 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 ...
- Classification Review Request CRR-2 – Position Change Request This form is for use by supervisors/managers when requesting a position schedule change, create a new position, reclassify a ...
- Classification Review Request CRR-3 This form is for use by supervisors/managers when requesting an incumbent filled position classification review. The ...
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Conflict of Interest Form
DHRM Rules R477-9-2 and R477-9-3 require that employment with the state be the principal vocation for full-time employees. A ...
- Employee Termination Checklist This checklist assists a supervisor with the exit of an employee and reminds them of state property that needs to be ...
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I9 Form
This form must be completed by ALL new hires no later than the first day of employment and Section 2 of this form along with ...
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IN/TL Agreement
Complete this form when hiring for an IN or TL position. Employee must sign.
Temporary Employee Agreement form 2018
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Overtime Agreement for Non-exempt Employees
Complete this form to select your overtime compensation pay if you are an FLSA non-exempt employee. Overtime agreement for ...
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Overtime Agreement for Officers
Complete this form to select your overtime compensation pay if you are an FLSA non-exempt Public Safety Officer, ...
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Personal Information Sheet for New Hires
This form provides all information required to enter a new employee into the Human Resource System. Personal Information ...
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Policy Acknowledgement
New hires must be provided with copies of or training related to the topics listed on this Acknowledgement Form, to ensure ...
- Position Classification Grievance Form Complete this form to notify your local Human Resource office you do not agree with a Classification decision. Position ...
- Reference Release Form Use this form when conducting interviews to authorize the release of reference information from a prior employer for an ...
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Request for Personnel Action
The EPAR system is the preferred method of request but there are some instances an HR representative may need to use this ...
- Schedule A Agreement Career Service Exempt Conversion Election Agreement & Acknowledgement Career Service Exempt Appointments
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URS Statement of Ineligibility
Utah Retirement Systems (URS) requires we notify a new employee they are not eligible for a retirement contribution made on ...
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Voluntary Termination
This form was created to assist employees with the resignation process which must be in writing, this form can be used or ...
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W4
Complete Form W-4 so your employer can withhold the correct federal income tax from your pay. Consider completing a new Form ...
Direct Hire Forms
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I9 Form
This form must be completed by ALL new hires no later than the first day of employment and Section 2 of this form along with ...
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IN/TL Agreement
Complete this form when hiring for an IN or TL position. Employee must sign.
Temporary Employee Agreement form 2018
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Overtime Agreement for Non-exempt Employees
Complete this form to select your overtime compensation pay if you are an FLSA non-exempt employee. Overtime agreement for ...
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Overtime Agreement for Officers
Complete this form to select your overtime compensation pay if you are an FLSA non-exempt Public Safety Officer, ...
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Personal Information Sheet for New Hires
This form provides all information required to enter a new employee into the Human Resource System. Personal Information ...
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Policy Acknowledgement
New hires must be provided with copies of or training related to the topics listed on this Acknowledgement Form, to ensure ...
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Request for Personnel Action
The EPAR system is the preferred method of request but there are some instances an HR representative may need to use this ...
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URS Statement of Ineligibility
Utah Retirement Systems (URS) requires we notify a new employee they are not eligible for a retirement contribution made on ...
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W4
Complete Form W-4 so your employer can withhold the correct federal income tax from your pay. Consider completing a new Form ...
Job Classification Forms
New Hire and Termination Forms
- Employee Termination Checklist This checklist assists a supervisor with the exit of an employee and reminds them of state property that needs to be ...
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Voluntary Termination
This form was created to assist employees with the resignation process which must be in writing, this form can be used or ...
Payroll Forms
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Blank Time Sheet
This is a blank time sheet to report hours if you are not able to complete time entry is ESS. This form must be completed ...
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Blank Time Sheet for Finet Coding
This is a blank time sheet to report hours coded to different projects or work sites if you are not able to complete time ...
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DEQ Blank Time Sheet (DEQ Employees Only)
Use this form if you are an employee of Department of Environmental Quality only.
DEQ ONLY Timesheet Excel
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FI21 Direct Deposit Form
Use this form to add new or updated direct deposit accounts for your paycheck. Additions and updates can also be made ...
- FI40A Private Vehicle Usage Reimbursement Complete this form to request mileage reimbursement for use of a private vehicle. Submit completed form to your agency ...
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FI40B Private Vehicle Usage Reimbursement
Complete this form to request mileage reimbursement when a state car is not available. Submit completed form to your ...
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FI41 Additional Withholding
Complete this form if you would like to have additional money withdrawn from you bi-weekly paycheck for Utah Income Tax ...
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FI48 Payroll Reimbursement Form
Complete this form to request reimbursement for travel related expenses, please be sure to attach required documentation and ...
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FI5 Request for Out-of-State Travel Authorization
Complete this form to request Out-of-State travel authorization. The link below will take you to the DAS Finance Forms web ...
- FI51A Travel Reimbursement Request (In State) Complete this form to submit a request for work related travel expenses. The link below will take you to the DAS Finance ...
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FI51B Travel Reimbursement Request (Out-of-State)
Complete this form to request reimbursement for Out-of-State travel expenses. Link to: Employee Out-of-State Travel ...
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FI5IS Request for In-State Travel Authorization
Complete this form to request authorization for In-State travel. The link below will take you to the DAS Finance Forms web ...
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FI7 Accepting Terms of Dual Employment
An employee who has more than one position with State government is considered to be in Dual Employment. An employee in ...
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Overtime Agreement for Non-exempt Employees
Complete this form to select your overtime compensation pay if you are an FLSA non-exempt employee. Overtime agreement for ...
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Overtime Agreement for Officers
Complete this form to select your overtime compensation pay if you are an FLSA non-exempt Public Safety Officer, ...
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Program I (Pre-2006) & Program II (Pre-2014) Sick & Converted Sick Leave Transfer Request
Complete this form to request a transfer of Program I (Pre-2006) and/or Program II (Pre-2014) Sick or Converted Sick to ...
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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 ...
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W4
Complete Form W-4 so your employer can withhold the correct federal income tax from your pay. Consider completing a new Form ...
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