Benefit Forms


PEBB Health Insurance Forms
PEBB Enrollment, Update, and Beneficiary Forms
PEBB Appeal Form
Health Insurance Reimbursement Forms
PEBB Statewide Plan  Forms (Providence) (Includes Medical Claim Form, Prescription drug claim form, prescription drug prior authorization form, etc)
Providence Choice Forms
Moda Medical & Dental Forms
Flexible Spending Account Claim Forms (Healthcare and Dependent Care) (.pdf file)
Flexible Spending Account - Other Forms
VSP Reimbursement Form  (.pdf file)
Family & Medical Leave
Medical Certification Form (.pdf file)
Tuition Reduction (Staff Fee Privileges)
Staff Fees Form - Employee
Staff Fees Form - Family Transfer

Public Employees Retirement System (PERS)

Optional Retirement Plan (ORP)

  • Change ORP plan vendor (sponsor) 1x time per calendar year (Fidelity to TIAA OR TIAA to Fidelity)

Tax Deferred Investment (TDI) 403(b) Plan

  • Online TDI 403(b) Enrollment/Monthly Contribution Change Form
    • Docusign (preferred)
    • Fillable PDF
    • Print Only
      • Complete the fillable PDF or printed form; redact your SSN and DOB and return to Employee Benefits:
        • Fax: (541) 737-0541

Oregon Savings Growth 457 Plan (OSGP)

Retiree Health Insurance Enrollment Forms
PEBB Retiree Health Insurance Application
PEBB Retiree Pay Type Option Form - submit with PEBB Retiree Application
PERS Health Insurance Forms
Workers' Compensation Forms
Office of Insurance and Risk Management Services website
Workers' Compensation forms
OSU Report of Accident (web form)
Important Information for Employees with Occupational Injuries (.pdf file)
Continued Benefits for Injured Workers Notice (.pdf file)