Madison County HR

Forms

For changes during November 1 through 15, please complete the Open Enrollment Process.

Health/Dental

• Enrollment

• New Dependent

• Dependent Cancellation 

• Status Change

• Declination of Coverage

• Wellness Provider Screening

Vision

• Enrollment

• Dependent Change

• Termination of Coverage

Flex

• Enrollment

Life

• Enrollment

• Beneficiary Change

• Coverage Change

• Terminate Coverage

• Rate Table

• Open Enrollment

Retirement

• Address Change

• Beneficiary Change

• Other ERS Forms

deferred comp

RSA-1

• Enrollment Packet

• Address Change

• Beneficiary Designation

• Investment Elections for Existing Accounts

• Authorization to Defer Compensation

Nationwide

• Enrollment/Change

• Beneficiary Change

• Divorce Proceedings

Address Change

• LGHIP Status Change

• RSA-1/ERS Address Change

• Portal Address Change (See Personal Information Section)

Payroll

• Direct Deposit (Visit Portal)

• Pre-Tax Authorization

• Federal W-4

• State A-4

​Leave

• Leave Transfer

• Sick Leave Bank Enrollment

• Sick Leave Bank Recipient Application

• Medical Emergency Certification (Sick Leave Bank)

FMLA

• Certification of Health Care Provider for Family Member’s Serious Health Condition

• Certification of Health Care Provider for Employee’s Serious Health Condition

• FML Leave Request

ADA

• Reasonable Accommodation Request

• Request for Temporary Transitional Light Duty

Personnel

•   Outside Employment Request

• Personnel Transfer

• Reclassification Request

• Request for Appeal

• Termination and Department Out-Processing

• Disciplinary Action

• Notice of Employee Disciplinary Hearing