Benefits Forms

Information about Benefits Forms and Supporting Documentation

Medical, Dental, and Flexible Spending Account Forms

Medical Enrollment and Change Form:

Flexible Spending Account (FSA) Enrollment Forms:

 

Health Plan Eligibility & Deduction Authorization for Both Spouse Employees Form:

     

    Disability Certification for Over-age Dependent Forms:

     

    Disability and Leaves Forms

    Family Medical Leave (FMLA) Forms:

     

    Leave of Absence (LOA) Form:

     

    Life Insurance Forms

    FCERS Life Insurance: MetLife for members of FCERS

    Most actions, including beneficiary designations, can be completed through your MetLife account. Go to MetLife's website at www.metlife.com/mybenefits. Under employer name, search for “Fairfax County Public Schools”. (First-time users will need to click “Register” to create their account.) 

    Please note: Cancellations of coverage cannot be done through MetLife’s website and must be done by phone or in writing.  

    • By phone: Contact MetLIfe at 1-866-492-6983.  Hours are Monday – Friday, from 8 a.m. to 11 p.m. ET.
    • In writing (be sure to include your name and other identifying information):  MetLife, PO Box 14401, Lexington, KY 40512-4401

    VRS Life Insurance: Securian Financial for members of VRS

     

    Retirement and Supplemental Retirement Savings Plans Forms

    457(b)

    Hybrid 457