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Benefit Forms

 
 
 
 

Benefit Forms

Form Use

Common-Law Affidavit

Employees wishing to add an opposite-sex spouse (without a marriage certificate) must complete the Common-Law Affidavit.

Please Note: If you were previously married and are adding a common-law spouse, you must provide a divorce decree for the prior marriage.

Spousal Equivalent Affidavit

Employees wishing to add a same-sex spouse must complete the Spousal Equivalent Affidavit.

Forms Use

Short-Term Disability Claim Form

Standard Insurance Company is the carrier for short-term disability. The city has 2 short-term disability plans. One is a voluntary benefit for those employees hired prior to January 1, 2010. This benefit is paid for by the employee through payroll deductions.  The other is an automatic benefit for those employees hired after January 1, 2010. This benefit is paid for by the city.

Additional Resources:

Long-Term Disability Claim Form

Standard Insurance is the carrier for the City and County of Denver's Long-Term Disability plan. All benefit-eligible employees are enrolled and premiums are provided to employees as part of their benefit package.

Additional Resources:

Form Use

Flex Spending Account Direct Deposit Form

Employees can use the 24HourFlex card to pay for eligible expenses, or file an online claim at www.24hourflex.com. You can also sign up for direct deposit at www.24HourFlex.com or complete this form to receive reimbursements directly to your bank account.

Addional Resources:

When enrolling in additional life insurance, medical history statements may be needed. Please see forms below.

Medical History Statement - electronic form

When enrolling for Supplemental/Additional Life and Accidental Death and Dismemberment coverage, if the employee and/or his/her spouse is required to submit evidence of insurability, complete a medical history statement and submit it directly to The Standard. Employees may submit the form electronically or a hard copy form, but they must not submit both. 

Additional Resources:

Medical History Statement - hard copy form

When enrolling for Supplemental/Additional Life and Accidental Death and Dismemberment coverage, if the employee and/or his/her spouse is required to submit evidence of insurability, complete a medical history statement and submit it directly to The Standard. Employees may submit the form electronically or a hard copy form, but they must not submit both. 

Additional Resources:

Form Use

Denver Employee Retirement Plan (DERP) Beneficiary Designation Form

To change the beneficiary of an employee's Denver Employees Retirment Plan (DERP) benefits. Completed forms may be returned directly to DERP.

Additional Resources:

 

 

Forms Use

EcoPass Enrollment Form

For employees to enroll in the city's subsidized Reginonal Transportation District (RTD) EcoPass.

Additional Resources:

EcoPass Termination Form

To terminate an employee’s Regional Transportation District (RTD) EcoPass, the employee must complete the EcoPass Termination form, turn the form and their RTD EcoPass in to OHR Benefits. OHR Benefits will keep the EcoPass on file and return it to the employee when they are ready to use it again (this avoids a $10 replacement fee charged by RTD).

RTD EcoPass to Replace ValuPass for DEN Employees
Beginning January 1, 2018, the RTD EcoPass program will replace the current ValuPass program that DEN employees have been using. EcoPass has been reduced to $10 pre-tax per month for all eligible City and County of Denver employees and will be applied to the second paycheck each month. EcoPass will save you money, get more cars off the road and support Mayor Michael B. Hancock’s Mobility Action Plan. EcoPass is a photo ID that does not need to be renewed each year, and you may enroll and cancel at any time. EcoPass can be used with no additional fees for rides on all buses, trains and light rail, except special rides like BroncosRide. The Office of Human Resources Benefits Office will contact employees currently using the ValuPass program within the next few days with instructions for getting your new EcoPass ID by the end of the year. Employees interested in enrolling in EcoPass should visit the benefit’s website for instructions.

 

Other forms:

COBRA Continuation Coverage

Your health benefits end when you no longer work for the city. Learn how you can continue your coverage with COBRA.

 

Contact us

Benefits questions?

Call: 720-913-5697
Email: benefits@denvergov.org