Internal Human Resource Forms

2019-2020 Summary of Benefits and Coverage (SBCs)

• Priority High Deductible Health Plan (HDHP) with HSA
• Understanding the HDHP HSA
• Priority HMO 100% High Plan
• Priority Health Medical Advantage (MAPD) Summary - Retirees
• Notice of Nondiscrimination and Language Assistance Services 
• Glossary of Health Coverage & Medical Terms
• Delta Dental - ACT, L&P ACT, GME-CT, FIRE, & L&P BU
• Delta Dental - Police & GME
• Vision Plan

Internal Forms for Current City Employees

PAYROLL FORMS

• 2020 FSA Enrollment Form
• Authorization for Automatic Deposit
• Authorization for Automatic Deposit - ACT 345
• W-4 Michigan Withholding Allowance Form
• W-4 Federal Withholding Allowance Form 2019

CHANGE FORMS

• Employee Address/Name Change Form

• Priority Health Insurance Change Form
• Opt-Out Form - Health Insurance
• MetLife Vision/Life Change Form
• Delta Dental Insurance Change Form
• HSA Salary Redirection Authorization 
• MERS Beneficiary Change Form 

• ICMA-RC 457 Deferred Comp. Change Form
• ICMA-RC 457 Deferred Comp. Beneficiary/Name & Address Change Form 
• ICMA-RC: Change Current and Future Allocations 

• MassMutual 457 Deferred Comp. Change Form
• MassMutual 457 Deferred Comp. Beneficiary/Name & Address Change Form 
• MassMutual: Change Current and Future Allocations 

REIMBURSEMENT FORMS

• Section 125 Plan - Dependent Care Claim Form
• Section 125 Plan - Limited Purpose Health FSA Claim Form 
• Educational Incentive Plan Request Form
• MERS Health Care Savings Plan (HCSP) Reimbursement Form

EMPLOYEE INFORMATION

• Employee Assistance Program 
• Injury Reporting Form
• FMLA Request for Leave Form
• Personal Leave of Absence Form
• City of Traverse City Notice of Privacy Practices

Michigan Municipal League Tuition Incentive Program