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

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.pdf
CT Partnership Plan 2.0.pdf

Partnership Plan 2.0 - Presentation.pdf

State of CT Health Allies-Final.pdf

2017 Oxford Healthy Bonus.pdf             

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

CVS Caremark - Prescriptions.pdf

 CVS Prescription Factsheet.pdf

State 2.0 Enrollment Form.pdf

State 2.0 Member Change Form.pdf

State of Connecticut Partnership Plan Clinical Programs.pdf


               



             ​
Miscellaneous Forms
Contracts
403(B) UNIVERSAL AVAILABILITY NOTICE
CUSTODIAN AGREEMENT Through 6-30-2016
Request for school sponsored field trip (updated)

ESG Contract 2016 - 2019

Volunteer Form

FOOD SERVICE WORKERS AGREEMENT through 2016

Visiting or Professional Day Request
 NFEP Local 1723 2013-2017


NFT Contract 2016-2019 Holiday Closings
NFT MOA re SpEd Case Managers Employee Holiday Schedules 2016-2017
NFT MOA re Extended Day and Time

NURSE'S CONTRACT 2016-2019
TECHNICIANS FULL AGREEMENT 2016-2019  
NASA 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