Life Status Changes

If you have experienced one of the following family status changes, you should consider making changes to your benefit package.

  • Birth or Adoption of a child
  • Marriage
  • Divorce
  • Legal name change
  • Death of family member
  • Dependent child reaches age 26
  • Reduction of work hours
  • Termination or loss of benefit coverage


  1. Complete Medical Insurance Enrollment change form
  2. Complete Dental Insurance Enrollment change form
  3. Complete new HRA enrollment form
  4. Review beneficiaries for City and Voluntary Life insurance policies
  5. Add or drop dependents from Voluntary Life policy
  6. Complete a new PERS or City Retirement Plan beneficiary form
  7. Review your W-4 tax withholding
  8. Review and/or update your Direct Deposit elections
  9. Complete a new Employee Profile form to change:
  • Address (can complete through Self-Service)
  • Phone numbers (can complete through Self-Service)
  • Emergency Contacts (can complete through Self-Service)
  • Marital Status (provide copy of certificate or decree to HR/Payroll)
  • Any legal name change (provide copy of updated id [Social Security card; driver license] for I-9 paperwork)

Life Status Changes:

Add Medical Dependent

ODS Change Form

HRA Change Form

(Marriage, birth of a child, adding dependent; paperwork due within 31 days of event)


Terminate Medical Dependent

ODS Change Form

HRA Change Form

Hartford – Coverage Cancellation

Hartford Beneficiary Change

(Divorce and/or dropping dependent; takes effect the month after event. Also consider changing beneficiaries)

Changing Beneficiaries:

Assurant Beneficiary Change

Hartford Beneficiary Change

PERS Beneficiary Change Form

(Elections can be done at any time)


DIRECTIONS – Employee Assistance Program (EAP)

This service provides confidential, professional counseling to help you successfully deal with personal problems that can interfere with everyday functioning, and provides training and organizational development to work groups to improve productivity and satisfaction in the workplace.

Contact Us

  • Confidential Fax in HR:  541-726-4614