Forms

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

• Personal Checks
• Refund Request Form

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, 2025)
• Active Notice of Election (for coverage effective January 1, 2024)
• 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

• Out-of-network Vision Services Claim Form
• Request for Medically Necessary Contact Lens Benefit Form
• Request for Medically Necessary Contact Lens Benefit Form (Out-of-network)

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

• Termination of Retired Member Working Under Earnings Limit
• Withholding Certificate for Monthly Benefit Payments.

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)

Trust certification

• Beneficiary/Trustee Designation Form (All Systems)
• Certification of Trust (All Systems)
• Certification of Nonexistent Trust (All Systems)