Browse the most current versions of the insurance and retirement benefits forms.
Insurance
A-C
- Absolute Assignment to Individual
- Absolute Assignment to Trust
- Accelerated Benefit Option
- Accidental Death & Dismemberment claim
- Active Notice of Election (for coverage effective January 1, 2024)
- Active Notice of Election (for coverage effective January 1, 2025)
- Active Part-time Teachers Notice of Election (for coverage effective January 1, 2024)
- Active Part-time Teachers Notice of Election (for coverage effective January 1, 2025)
- Active Termination Form
- Appeal Request Form
- Authorization to Release Protected Health Information
- Authorized Representative Form
- Certification Regarding Tobacco and E-cigarette Use
- COBRA Ineligibility Form for Dependents
- COBRA Notice of Election
- COBRA sample 18-month instruction sheet and notification letter
- COBRA sample 36-month instruction sheet and notification letter
- COBRA sample initial instruction sheet and notification letter (for all gains of coverage)
D-F
- Dental Claim Form
- Dependent Social Security Number
- Designated Governmental Entity Form
- Employment Verification Record
- Former Spouse Notice of Election
G-P
- Health Savings Account Transfer Form (from Optum Bank)
- Health Savings Account Transfer Form (from other custodial bank)
- Incapacitated Child Certification
- Letter of Medical Necessity
- Life insurance claim
- LTD Benefits Claim Form packet
- Marketplace Exchange Notice
- Medical History Statement for Late Entrants and instructions
- Medicare Prescription Drug Program enrollment request
- MoneyPlus Appeal Form
- MoneyPlus Claim Form
- Name/Address Change
- Notice of COBRA Qualifying Event
- Notice of Special Enrollment Rights
- Notice to Extend COBRA Continuation Coverage
- Notice to Terminate COBRA Continuation Coverage
- Out-of-network Vision Services Claim Form
- Paperless Notification and Payment Authorization (Direct Deposit)
- Personal Checks
- Prescription Drug Claim Form
- Prescription Drug Mail Order Form
Q-S
- Refund Request Form
- Request for Long Term Disability Conversion Materials
- Request for Medically Necessary Contact Lens Benefit Form
- Request for Medically Necessary Contact Lens Benefit Form (Out-of-network)
- Request for Review (employer request for change due to clerical error)
- Retiree Notice of Election
- Retiree Packet
- SLTD Premium Waiver Form
- State Health Plan: Health Expenses Claim Form
- State Health Plan: International Claim Form
- Survivor Notice of Election
T-Z
Accounting
Affordable Care Act (ACA)
- Designated Governmental Entity Form
- Your Insurance Benefits When Your Hours are Reduced
- Marketplace Exchange Notice
COBRA
- COBRA sample initial instruction sheet and notification letter (for all gains of coverage)
- COBRA sample 18-month instruction sheet and notification letter
- COBRA sample 36-month instruction sheet and notification letter
- Notice of COBRA Qualifying Event
- COBRA Ineligibility Form for Dependents
- Notice to Extend COBRA Continuation Coverage
- Notice to Terminate COBRA Continuation Coverage
Dental care
Employer
- EBS Confidentiality Agreement
- EBS Authorizing Agent Designation Form
- EBS Designated Employee Confidentiality Agreement
- TPE Designated Employee Confidentiality Agreement
- Memo of Understanding for Third-Party Enrollers
- Request for Review (employer request for change due to clerical error)
Health insurance
- Certification Regarding Tobacco and E-cigarette Use
- State Health Plan: Health Expenses Claim Form
- State Health Plan: International Claim Form
Life insurance
- Life insurance claim
- Accidental Death & Dismemberment claim
- Accelerated Benefit Option
- Absolute Assignment to Individual
- Absolute Assignment to Trust
Long term disability
- Medical History Statement for Late Entrants and instructions
- LTD Benefits Claim Form packet
- Request for Long Term Disability Conversion Materials
- SLTD Premium Waiver Form
MoneyPlus
- Claim Form
- Paperless Notification and Payment Authorization (Direct Deposit)
- Authorization to Release Protected Health Information
- Letter of Medical Necessity
- Appeal Form
- Health Savings Account Transfer Form (from Optum Bank)
- Health Savings Account Transfer Form (from other custodial bank)
Notice of election
- Active Notice of Election (for coverage effective January 1, 2024)
- Active Notice of Election (for coverage effective January 1, 2025)
- Active Part-time Teachers Notice of Election (for coverage effective January 1, 2024)
- Active Part-time Teachers Notice of Election (for coverage effective January 1, 2025)
- Active Termination Form
- Retiree Notice of Election
- COBRA Notice of Election
- Survivor Notice of Election
- Former Spouse Notice of Election
Other forms
- Name/Address Change
- Retiree Packet
- Notice of Special Enrollment Rights
- Employment Verification Record
- Incapacitated Child Certification
- Dependent Social Security Number
- Authorized Representative Form
- Appeal Request Form
Prescription benefits
- Prescription Drug Claim Form
- Prescription Drug Mail Order Form
- Medicare Prescription Drug Program enrollment request
Vision care
Retirement
0-9
- 12-Month Break-in-Service Exemption Certification
- 48-Month Rule Request to Terminate Benefits and Return to Active Service
A-C
- ACH Debit Authorization
- Adjustment to Quarterly Payroll Report (South Carolina Retirement System, Police Officers Retirement System)
- Administrative Appeal Disability Report
- Application to Append Coverage for Incidental Death Benefit (SCRS)
- Application to Append Coverage for Incidental Death Benefit, Accidental Death Program and/or Firefighters Coverage (PORS)
- Authorization for Release of Information
- Authorized Representative Form
- Beneficiary Form - Beneficiary Designation, Contingent Beneficiary (All Systems)
- Beneficiary/Trustee Designation Form (All Systems)
- Certification of Nonexistent Trust (All Systems)
- Certification of Trust (All Systems)
D-F
- Deduction Form, Public Safety Officer Insurance Payment Program - EIP Only
- Deduction Form, Public Safety Officer Insurance Payment Program - Non-EIP
- Deferred benefit Account (JSRS) Payout Form
- Direct Deposit Authorization
- Due Date Calendar
- Election of Non-Membership
- Electronic Employer Services (EES) Authorizing Contact Designation/Agreement
- Electronic Employer Services (EES) Designated Agent Confidentiality Agreement
- Electronic Employer Services (EES) Employer Confidentiality Agreement
- Electronic Employer Services (EES) Payment Authorization Agreement
- Employer Certification of Police Officers Retirement System (PORS) Eligibility
- Employer Eligibility Determination Request
- Employer Resolution And Application (PORS)
- Employer Resolution And Application (SCRS)
- Employer Resolution on Tax Deferred Payroll Deductions for Installment Purchase
- Employer's Description of Disability Applicant's Job
- Employer's Disability Employment Status Report
- Enrollment Form (All Systems)
- Fiscal Year Contribution Rates
G-P
- General Assembly Retirement System Application for Service Retirement Benefits
- General Assembly Retirement System Special Contributing Member Election
- Installment Service Purchase Remittance
- Judges and Solicitors' Retirement System Application for Service Retirement Benefits
- Member's Disability Report
- Name/Address Change Form
- Police Officers Retirement System Application for Disability Retirement
- Police Officers Retirement System Application for Service Retirement Benefits
Q-S
- Refund Request (South Carolina Retirement System, Police Officers Retirement System)
- Request for 48-Month Rule Eligibility
- Request for ORP Service Verification (Applies to ORP service in South Carolina only.)
- Request for Public/Educational Service Verification
- Request for Retirement Benefit Estimate (All Systems)
- Request for Service Purchase Cost (All Systems)
- Requirements for a Participant to Revoke Election to Participate
- Retired Member Change of Beneficiary (South Carolina Retirement System, Police Officers Retirement System)
- Retired Member Change of Beneficiary Form (GARS)
- Retiring Member's Disability Application Checklist
- Retiring Member's Service Application Checklist
- School Resource Officer Critical Needs Certification
- SCNG Service Retirement Application
- Service Purchase Federal Address List
- Service Purchase Payment Options (All Systems)
- Service Purchase Salary Verification
- South Carolina Retirement System Application for Disability Retirement
- South Carolina Retirement System Application for Service Retirement Benefits
- Standard Retirement Quarterly Report - Class I Employer (South Carolina Retirement System, Police Officers Retirement System)
- Standard Retirement Quarterly Report (South Carolina Retirement System, Police Officers Retirement System)
- State Optional Retirement Program (ORP) Active Incidental Death Benefit Beneficiary Form (South Carolina Retirement System)
- State Optional Retirement Program (State ORP) Notice of Termination or Change
- Supplemental Contribution Report
- Supplemental Service Report (South Carolina Retirement System, Police Officers Retirement System)
T-Z
1000 Series
- 1100 Enrollment Form (All Systems)
- 1102 Beneficiary Form - Beneficiary Designation, Contingent Beneficiary (All Systems)
- 1103 Beneficiary/Trustee Designation Form (All Systems)
- 1104 Election of Non-Membership
- 1106 State Optional Retirement Program (ORP) Active Incidental Death Benefit Beneficiary Form (South Carolina Retirement System)
- 1107 Employer Certification of Police Officers Retirement System (PORS) Eligibility
- 1113 Certification of Trust (All Systems)
- 1162 State Optional Retirement Program (State ORP) Notice of Termination or Change
- 1221 Standard Retirement Quarterly Report (South Carolina Retirement System, Police Officers Retirement System)
- 1222 Standard Retirement Quarterly Report - Class I Employer (South Carolina Retirement System, Police Officers Retirement System)
- 1223 Adjustment to Quarterly Payroll Report (South Carolina Retirement System, Police Officers Retirement System)
- 1224 Supplemental Service Report (South Carolina Retirement System, Police Officers Retirement System)
- 1226 ACH Debit Authorization
- 1227 Supplemental Contribution Report
- 1239 Name/Address Change Form
- 1286 EES Electronic Payment Authorization Agreement
- 1340 Fiscal Year Contribution Rates
- 1341 Due Date Calendar
2000 Series
- 2101 Request for Service Purchase Cost (All Systems)
- 2122 Request for Public/Educational Service Verification
- 2130 Request for ORP Service Verification (Applies to ORP service in South Carolina only.)
- 2140 General Assembly Retirement System Special Contributing Member Election
- 2209 Service Purchase Salary Verification
- 2390 Service Purchase Payment Options (All Systems)
- 2391 Service Purchase Federal Address List
3000 Series
- 3227A Requirements for a Participant to Revoke Election to Participate
- 3228 Employer Resolution on Tax Deferred Payroll Deductions for Installment Purchase
- 3229 Installment Service Purchase Remittance
4000 Series
- 4101 Refund Request (South Carolina Retirement System, Police Officers Retirement System)
- 4257 Certification of Nonexistent Trust (All Systems)
6000 Series
- 6100 Request for Retirement Benefit Estimate (All Systems)
- 6101G General Assembly Retirement System Application for Service Retirement Benefits
- 6101J Judges and Solicitors' Retirement System Application for Service Retirement Benefits
- 6101N SCNG Service Retirement Application
- 6101P Police Officers Retirement System Application for Service Retirement Benefits
- 6101S South Carolina Retirement System Application for Service Retirement Benefits
- 6151P Police Officers Retirement System Application for Disability Retirement
- 6151S South Carolina Retirement System Application for Disability Retirement
- 6251 Member's Disability Report
- 6253 Employer's Disability Employment Status Report
- 6254 Employer's Description of Disability Applicant's Job
- 6255 Authorization for Release of Information
- 6291 Administrative Appeal Disability Report
- 6302 Retiring Member's Service Application Checklist
- 6352 Retiring Member's Disability Applications Checklist
- 6500 Employer Eligibility Determination Request
- 6501 Employer Resolution and Application (SCRS)
- 6501P Employer Resolution and Application (PORS)
- 6502 Application to Append Coverage for Incidental Death Benefit (SCRS)
- 6502P Application to Append Coverage for Incidental Death Benefit, Accidental Death Program and/or Firefighters Coverage (PORS)
- 6503 Electronic Employer Services (EES) Employer Confidentiality Agreement
- 6504 Electronic Employer Services (EES) Authorizing Contact Designation/Agreement
- 6505 Electronic Employer Services (EES) Designated Agent Confidentiality Agreement
7000 Series
- 7100 48-Month Rule Request to Terminate Benefits and Return to Active Service
- 7101 Request for 48-Month Rule Eligibility
- 7201 Retired Member Change of Beneficiary (South Carolina Retirement System, Police Officers Retirement System)
- 7201G Retired Member Change of Beneficiary Form (GARS)
- 7202 Withholding Certificate for Monthly Benefit Payments
- 7204 Direct Deposit Authorization
- 7213 Authorized Representative Form
- 7214 School Resource Officer Critical Needs Certification
- 7217 Termination of Retired Member Working Under Earnings Limit
- 7218 12-Month Break-in-Service Exemption Certification
- 7500 Teacher and Employee Retention Incentive (TERI) Payout Election Form
- 7700 Deduction Form, Public Safety Officer Insurance Payment Program - EIP Only
- 7701 Deduction Form, Public Safety Officer Insurance Payment Program - Non-EIP
- 7800 Deferred benefit Account (JSRS) Payout Form
Death
- Refund Request (South Carolina Retirement System, Police Officers Retirement System)
- Certification of Nonexistent Trust (All Systems)
- Application to Append Coverage for Incidental Death Benefit (SCRS)
- Application to Append Coverage for Incidental Death Benefit, Accidental Death Program and/or Firefighters Coverage (PORS)
- Withholding Certificate for Monthly Benefit Payments
Employer
- Employer Certification of Police Officers Retirement System (PORS) Eligibility
- Standard Retirement Quarterly Report (South Carolina Retirement System, Police Officers Retirement System)
- Standard Retirement Quarterly Report - Class I Employer (South Carolina Retirement System, Police Officers Retirement System)
- Adjustment to Quarterly Payroll Report (South Carolina Retirement System, Police Officers Retirement System)
- Supplemental Service Report (South Carolina Retirement System, Police Officers Retirement System)
- ACH Debit Authorization
- Supplemental Contribution Report
- Fiscal Year Contribution Rates
- Due Date Calendar
- Service Purchase Salary Verification
- Employer Resolution on Tax Deferred Payroll Deductions for Installment Purchase
- Employer's Disability Employment Status Report
- Employer Eligibility Determination Request
- Employer Resolution and Application (SCRS)
- Employer Resolution and Application (PORS)
- Electronic Employer Services (EES) Employer Confidentiality Agreement
- Electronic Employer Services (EES) Authorizing Contact Designation/Agreement
- Electronic Employer Services (EES) Designated Agent Confidentiality Agreement
- Electronic Employer Services (EES) Payment Authorization Agreement
- Deduction Form, Public Safety Officer Insurance Payment Program - EIP Only
- Deduction Form, Public Safety Officer Insurance Payment Program - Non-EIP
- Termination of Retired Member Working Under Earnings Limit
Enrollment
- Enrollment Form (All Systems)
- Beneficiary Form - Beneficiary Designation, Contingent Beneficiary (All Systems)
- Beneficiary/Trustee Designation Form (All Systems)
- Election of Non-Membership
- State Optional Retirement Program (ORP) Active Incidental Death Benefit Beneficiary Form (South Carolina Retirement System)
- Certification of Trust (All Systems)
GARS
- Name/Address Change Form
- General Assembly Retirement System Special Contributing Member Election
- General Assembly Retirement System Application for Service Retirement Benefits
- Direct Deposit Authorization
Installment
- Requirements for a Participant to Revoke Election to Participate
- Installment Service Purchase Remittance
JSRS
- Name/Address Change Form
- Judges and Solicitors' Retirement System Application for Service Retirement Benefits
- Deferred benefit Account (JSRS) Payout Form
Leaving covered employment
PORS
- Employer Certification of Police Officers Retirement System (PORS) Eligibility
- Name/Address Change Form
- Fiscal Year Contribution Rates
- Police Officers Retirement System Application for Service Retirement Benefits
- Police Officers Retirement System Application for Disability Retirement
- Member's Disability Report
- Employer's Description of Disability Applicant's Job
- Authorization for Release of information
- School Resource Officer Critical Needs
- Employer Resolution And Application (PORS)
- Application to Append Coverage for Incidental Death Benefit, Accidental Death Program and/or Firefights Coverage (PORS)
- Direct Deposit Authorization
- 12-Month Break-in-Service Exemption Certification
Public safety
- Deduction Form, Public Safety Officer Insurance Payment Program - EIP Only
- Deduction Form, Public Safety Officer Insurance Payment Program - Non-EIP
Refund
Retirement - disability
- Police Officers Retirement System Application for Disability Retirement
- South Carolina Retirement System Application for Disability Retirement
- Employer's Disability Employment Status Report
- Administrative Appeal Disability Report
- Retiring Member's Disability Applications Checklist
- Direct Deposit Authorization
Retirement - service
- General Assembly Retirement System Application for Service Retirement Benefits
- Judges and Solicitors' Retirement System Application for Service Retirement Benefits
- SCNG Service Retirement Application
- Police Officers Retirement System Application for Service Retirement Benefits
- South Carolina Retirement System Application for Service Retirement Benefits
- Retiring Member's Service Application Checklist
- Withholding Certificate for Monthly Benefit Payments
- Direct Deposit Authorization
Returning to covered employment
- 48-Month Rule Request to Terminate Benefits and Return to Active Service
- Request for 48-Month Rule Eligibility
SCRS
- Name/Address Change Form
- Fiscal Year Contribution Rates
- South Carolina Retirement System Application for Service Retirement Benefits
- South Carolina Retirement System Application for Disability Retirement
- Employer Resolution and Application (SCRS)
- Application to Append Coverage for Incidental Death Benefits (SCRS)
- Direct Deposit Authorization
- Teacher and Employee Retention Incentive (TERI) Payout Election Form
- 12-Month Break-in-Service Exemption Certification
Service purchase
- Request for Service Purchase Cost (All Systems)
- Request for Public/Educational Service Verification
- Request for ORP Service Verification (Applies to ORP service in South Carolina only)
- General Assembly Retirement System Special Contributing Member Election
- Service Purchase Salary Verification
- Service Purchase Payment Options (All Systems)
- Service Purchase Federal Address List
- Requirements for a participant to Revoke Election to Participate
- Installment Service Purchase Remittance
State ORP
- Election of Non-Membership
- State Optional Retirement Program (ORP) Active Incidental Death Benefit Beneficiary Form (South Carolina Retirement System)
- Name/Address Change Form
- State Optional Retirement Program (State ORP) Notice of Termination or Change
- Fiscal Year Contribution Rates
- Request for ORP Service Verification (Applies to ORP service in South Carolina only)