Admin

Current Employees


Below is a list of forms for existing employees. Click a link to go directly to a particular form. All forms are in adobe Acrobat (PDF) format.

Use the "Tab" key to move between fields while completing a form. please complete the form and sign where required prior to mailing or faxing. If you fax the form, please mail the hard copy so that we have your original signature.

Our mailing address is:

         Attention: Human Resources
         125 East Avenue
         Post Office Box 6001
         Norwalk, CT 06852-6001

Our fax number is:        
203-854-4095

   Employee Self Service
   
Medical Forms
FMLA Forms
ANTHEM ENROLLMENT-MEMBER CHANGE FORM FMLA - Employee
DELTA DENTAL ENROLLMENT FORM
FMLA - Spouse/Family

FMLA - Military

FMLA - Poster
AETNA-Life Insurance Beneficiary Designation Form
FMLA - The Employee's Guide
Delta Dental Claim Form  
IPI Dental Claim Form
FSA (Flexible Spending Account) Forms
Anthem Claim Form - Vision ONLY
Affadavit and Federal 1040 Tax Form Dependent Confirmation
FSA 2017 Enrollment Form- LTD Purpose
2017 Flu Shot Consent
FSA 2017 Enrollment Form- Health & Dependent Care
  FSA Reimbursement Form
Personnel Forms  FSA Qualifying Expenses 
Personal Day Request FSA 2017 Booklet 

Health Insurance Information

Partnership Plan Brochure
CT Partnership Plan 2.0

Partnership Plan 2.0 - Presentation

State of CT Health Allies-Final

2017 Oxford Healthy Bonus            

HEP Preventive Requirements
State of Ct HEP for Partnership Plans new 2-12 2017

CVS Caremark - Prescriptions

 CVS Prescription Factsheet

State 2.0 Enrollment Form

State 2.0 Member Change Form

State of Connecticut Partnership Plan Clinical Programs.pdf
Norwalk BOE - Vision Benefit Summary

Instructions to Print Connecticut 2.0 Cards              
Connecticut 2.0 Insurance Roll-Out Information


             ​
Miscellaneous Forms
Contracts
403(B) Universal Availability Notice
UPSEU Contract thru June 30, 2020
Request for school sponsored field trip
ESG Contract 2016 - 2019

Volunteer Form

Food Service Contract, Expired 2016

Visiting or Professional Day Request
 NFEP Local 1723 2013-2017
Teacher Evaluation Professional Learning Plan

NFT Contract 2016-2019 Holiday and Weather Related Closings
NFT MOA re SPED Case Managers School Building/Office Holiday Schedule for 2017-2018
NFT MOA re Extended Day and Time Inclement Weather Procedures 2017-2018
HCE Nurse's Contract 2016-2019
UFT Technician's Contract 2016-2019  
NASA Administrator's Contract 2015-2018  

Important Information from Anthem
Anthem has released information and advice to customers on how to protect themselves from scam email campaigns. Please click on the link to read the Anthem news release: 
Anthem News Release 

A Communications Update from Anthem is available here: Anthem Update 2/12/2014