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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
  • 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
  • City of Traverse City Notice of Privacy Practices

Michigan Municipal League Tuition Incentive Program

This page last updated on 5/30/2019.