Documentation to add a dependent

• Marriage License – to add a spouse or stepchild
• ARBenefits Spousal Affidavit form – to add a spouse
• Birth Certificate/adoption paperwork – to add a child
• Proof of prior coverage (must include names and dates of coverage) – to add yourself, a spouse, or a child due to loss of coverage

Documentation to drop a dependent

• Divorce Decree – to drop a spouse due to divorce
• Proof of other coverage (must include names and dates of coverage) – to drop coverage on yourself, a child, or a spouse due to a gain of other coverage

Health Savings Account (HSA)

An HSA allows you to use pre-tax funds to cover eligible expenses. These are offered through Optum Financial

Eligibility: Must be on the Basic Plan or Classic Plan
Contributions: Can be adjusted anytime
Account Access: Will still be available even after you leave
your employer
Enrollment: Do not need to re-enroll each year
Rollover of Funds: Funds will rollover

• 2022 HSA Enrollment Form
• HSA Claim Form
• Change of Status Form
• HSA Transfer Request Form

Flexible Spending Account (FSA)

An FSA allows you to use pre-tax funds to cover eligible expenses. Medical FSA can be used on eligible medical expenses. Dependent Care FSA (or DCAP) can be used on expenses relating to daycare and elder care. Limited Purpose FSA can be paired with a HSA to be used on dental and vision expenses.

• Eligibility: Must be on the Premium Plan or No Health to enroll
• Contributions: Can only be adjusted during Open Enrollment, the new hire period, or if you have a qualifying event.
• Account Access: Will be lost after you leave your employer
• Enrollment: Must re-enroll each year
• Rollover of Funds: Funds over $550 do not rollover

• 2022 FSA Enrollment Form
• FSA Claim Form

Dental and Vision

Delta Dental and Humana Vision are both available to State employees through Arkansas State Employee Benefits Advisors (ARSEBA).

Dental Plan Comparison
Delta Dental Enrollment Form
Humana Vision Benefit Summary
Humana Vision Application

Life Insurance

Colonial Life’s group term life insurance can help provide
financial security for your family. See below for more information on options through Colonial Life.

Colonial Life Enrollment and Rates
Basic and Enhanced Basic Coverage Brochure
Supplemental Coverage Brochure
Colonial Life Change Form
Colonial Life Beneficiary Change Form
Colonial Life Evidence of Insurability

RETIREE FORMS AND RESOURCES

General Forms

• Affidavit of Spousal Coverage Form
• Authorization to Release Information
• Bank Draft Authorization Form
• Retiree Change of Address Form
• Retiree Health Enrollment and Instructions
• State Retiree Packet
• School Retiree Packet
• Retiree Election Form

Dental and Vision

• Dental and Vision Plan Information
• Dental and Vision Plan Application

Colonial Life Retiree

• Colonial Life Retiree Enrollment Form
• Colonial Life Retiree Rates & Information
• Colonial Life Retiree Beneficiary Change Form
• Colonial Life Retiree Change Form