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
- 2023 Active Notice of Electionexternal link, opens in a new tab (for coverage effective January 1, 2023)
- 2023 Active Part-time Teachers Notice of Electionexternal link, opens in a new tab (for coverage effective January 1, 2023)
- Active Termination Form
- Appeal Request Form
- Authorization to Release Protected Health Information
- Authorized Representative Formexternal link, opens in a new tab
- 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 Changeexternal link, opens in a new tab
- 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
- 2023 Active Notice of Electionexternal link, opens in a new tab (for coverage effective January 1, 2023)
- 2023 Active Part-time Teachers Notice of Electionexternal link, opens in a new tab (for coverage effective January 1, 2023)
- Active Termination Form
- Retiree Notice of Election
- COBRA Notice of Election
- Survivor Notice of Election
- Former Spouse Notice of Election
Other forms
- Name/Address Changeexternal link, opens in a new tab
- Retiree Packet
- Notice of Special Enrollment Rights
- Employment Verification Record
- Incapacitated Child Certification
- Dependent Social Security Number
- Authorized Representative Formexternal link, opens in a new tab
- 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
A-C
- ACH Debit Authorizationexternal link, opens in a new tab
- Adjustment to Quarterly Payroll Report (South Carolina Retirement System, Police Officers Retirement System)external link, opens in a new tab
- Administrative Appeal Disability Reportexternal link, opens in a new tab
- Application to Append Coverage for Incidental Death Benefit (SCRS)external link, opens in a new tab
- Application to Append Coverage for Incidental Death Benefit, Accidental Death Program and/or Firefighters Coverage (PORS)external link, opens in a new tab
- Authorization for Release of Informationexternal link, opens in a new tab
- Authorized Representative Formexternal link, opens in a new tab
- Beneficiary Form - Beneficiary Designation, Contingent Beneficiary (All Systems)external link, opens in a new tab
- Beneficiary/Trustee Designation Form (All Systems)external link, opens in a new tab
- Certification of Nonexistent Trust (All Systems)external link, opens in a new tab
- Certification of Trust (All Systems)external link, opens in a new tab
- COVID-19 Earnings Limitation Exception Certificationexternal link, opens in a new tab
D-F
- Deduction Form, Public Safety Officer Insurance Payment Program - EIP Onlyexternal link, opens in a new tab
- Deduction Form, Public Safety Officer Insurance Payment Program - Non-EIPexternal link, opens in a new tab
- Deferred benefit Account (JSRS) Payout Formexternal link, opens in a new tab
- Direct Deposit Authorizationexternal link, opens in a new tab
- Due Date Calendarexternal link, opens in a new tab
- Election of Non-Membershipexternal link, opens in a new tab
- Electronic Employer Services (EES) Authorizing Contact Designation/Agreementexternal link, opens in a new tab
- Electronic Employer Services (EES) Designated Agent Confidentiality Agreementexternal link, opens in a new tab
- Electronic Employer Services (EES) Employer Confidentiality Agreementexternal link, opens in a new tab
- Electronic Employer Services (EES) Payment Authorization Agreementexternal link, opens in a new tab
- Employer Certification of Police Officers Retirement System (PORS) Eligibilityexternal link, opens in a new tab
- Employer Eligibility Determination Requestexternal link, opens in a new tab
- Employer Resolution And Application (PORS)external link, opens in a new tab
- Employer Resolution And Application (SCRS)external link, opens in a new tab
- Employer Resolution on Tax Deferred Payroll Deductions for Installment Purchaseexternal link, opens in a new tab
- Employer's Description of Disability Applicant's Jobexternal link, opens in a new tab
- Employer's Disability Employment Status Reportexternal link, opens in a new tab
- Enrollment Form (All Systems)external link, opens in a new tab
- Fiscal Year Contribution Ratesexternal link, opens in a new tab
G-P
- General Assembly Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
- General Assembly Retirement System Special Contributing Member Electionexternal link, opens in a new tab
- Installment Service Purchase Remittanceexternal link, opens in a new tab
- Judges and Solicitors' Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
- Member's Disability Reportexternal link, opens in a new tab
- Name/Address Change Formexternal link, opens in a new tab
- Police Officers Retirement System Application for Disability Retirementexternal link, opens in a new tab
- Police Officers Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
Q-S
- Refund Request (South Carolina Retirement System, Police Officers Retirement System)external link, opens in a new tab
- Request for ORP Service Verification (Applies to ORP service in South Carolina only.)external link, opens in a new tab
- Request for Public/Educational Service Verificationexternal link, opens in a new tab
- Request for Retirement Benefit Estimate (All Systems)external link, opens in a new tab
- Request for Service Purchase Cost (All Systems)external link, opens in a new tab
- Requirements for a Participant to Revoke Election to Participateexternal link, opens in a new tab
- Retired Member Change of Beneficiary (South Carolina Retirement System, Police Officers Retirement System)external link, opens in a new tab
- Retired Member Change of Beneficiary Form (GARS)external link, opens in a new tab
- Retiring Member's Disability Application Checklistexternal link, opens in a new tab
- Retiring Member's Service Application Checklistexternal link, opens in a new tab
- School Resource Officer Critical Needs Certificationexternal link, opens in a new tab
- SCNG Service Retirement Applicationexternal link, opens in a new tab
- Service Purchase Federal Address Listexternal link, opens in a new tab
- Service Purchase Payment Options (All Systems)external link, opens in a new tab
- Service Purchase Salary Verificationexternal link, opens in a new tab
- South Carolina Retirement System Application for Disability Retirementexternal link, opens in a new tab
- South Carolina Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
- Standard Retirement Quarterly Report - Class I Employer (South Carolina Retirement System, Police Officers Retirement System)external link, opens in a new tab
- Standard Retirement Quarterly Report (South Carolina Retirement System, Police Officers Retirement System)external link, opens in a new tab
- State Optional Retirement Program (ORP) Active Incidental Death Benefit Beneficiary Form (South Carolina Retirement System)external link, opens in a new tab
- State Optional Retirement Program (State ORP) Notice of Termination or Changeexternal link, opens in a new tab
- Supplemental Contribution Reportexternal link, opens in a new tab
- Supplemental Service Report (South Carolina Retirement System, Police Officers Retirement System)external link, opens in a new tab
T-Z
1000 Series
- 1100external link, opens in a new tab Enrollment Form (All Systems)
- 1102external link, opens in a new tab Beneficiary Form - Beneficiary Designation, Contingent Beneficiary (All Systems)
- 1103external link, opens in a new tab Beneficiary/Trustee Designation Form (All Systems)
- 1104external link, opens in a new tab Election of Non-Membership
- 1106external link, opens in a new tab State Optional Retirement Program (ORP) Active Incidental Death Benefit Beneficiary Form (South Carolina Retirement System)
- 1107external link, opens in a new tab Employer Certification of Police Officers Retirement System (PORS) Eligibility
- 1113external link, opens in a new tab Certification of Trust (All Systems)
- 1162external link, opens in a new tab State Optional Retirement Program (State ORP) Notice of Termination or Change
- 1221external link, opens in a new tab Standard Retirement Quarterly Report (South Carolina Retirement System, Police Officers Retirement System)
- 1222external link, opens in a new tab Standard Retirement Quarterly Report - Class I Employer (South Carolina Retirement System, Police Officers Retirement System)
- 1223external link, opens in a new tab Adjustment to Quarterly Payroll Report (South Carolina Retirement System, Police Officers Retirement System)
- 1224external link, opens in a new tab Supplemental Service Report (South Carolina Retirement System, Police Officers Retirement System)
- 1226external link, opens in a new tab ACH Debit Authorization
- 1227external link, opens in a new tab Supplemental Contribution Report
- 1239external link, opens in a new tab Name/Address Change Form
- 1286external link, opens in a new tab EES Electronic Payment Authorization Agreement
- 1340external link, opens in a new tab Fiscal Year Contribution Rates
- 1341external link, opens in a new tab Due Date Calendar
2000 Series
- 2101external link, opens in a new tab Request for Service Purchase Cost (All Systems)
- 2122external link, opens in a new tab Request for Public/Educational Service Verification
- 2130external link, opens in a new tab Request for ORP Service Verification (Applies to ORP service in South Carolina only.)
- 2140external link, opens in a new tab General Assembly Retirement System Special Contributing Member Election
- 2209external link, opens in a new tab Service Purchase Salary Verification
- 2390external link, opens in a new tab Service Purchase Payment Options (All Systems)
- 2391external link, opens in a new tab Service Purchase Federal Address List
3000 Series
- 3227Aexternal link, opens in a new tab Requirements for a Participant to Revoke Election to Participate
- 3228external link, opens in a new tab Employer Resolution on Tax Deferred Payroll Deductions for Installment Purchase
- 3229external link, opens in a new tab Installment Service Purchase Remittance
4000 Series
- 4101external link, opens in a new tab Refund Request (South Carolina Retirement System, Police Officers Retirement System)
- 4257external link, opens in a new tab Certification of Nonexistent Trust (All Systems)
6000 Series
- 6100external link, opens in a new tab Request for Retirement Benefit Estimate (All Systems)
- 6101Gexternal link, opens in a new tab General Assembly Retirement System Application for Service Retirement Benefits
- 6101Jexternal link, opens in a new tab Judges and Solicitors' Retirement System Application for Service Retirement Benefits
- 6101Nexternal link, opens in a new tab SCNG Service Retirement Application
- 6101Pexternal link, opens in a new tab Police Officers Retirement System Application for Service Retirement Benefits
- 6101Sexternal link, opens in a new tab South Carolina Retirement System Application for Service Retirement Benefits
- 6151Pexternal link, opens in a new tab Police Officers Retirement System Application for Disability Retirement
- 6151Sexternal link, opens in a new tab South Carolina Retirement System Application for Disability Retirement
- 6251external link, opens in a new tab Member's Disability Report
- 6253external link, opens in a new tab Employer's Disability Employment Status Report
- 6254external link, opens in a new tab Employer's Description of Disability Applicant's Job
- 6255external link, opens in a new tab Authorization for Release of Information
- 6291external link, opens in a new tab Administrative Appeal Disability Report
- 6302external link, opens in a new tab Retiring Member's Service Application Checklist
- 6352external link, opens in a new tab Retiring Member's Disability Applications Checklist
- 6500external link, opens in a new tab Employer Eligibility Determination Request
- 6501external link, opens in a new tab Employer Resolution and Application (SCRS)
- 6501Pexternal link, opens in a new tab Employer Resolution and Application (PORS)
- 6502external link, opens in a new tab Application to Append Coverage for Incidental Death Benefit (SCRS)
- 6502Pexternal link, opens in a new tab Application to Append Coverage for Incidental Death Benefit, Accidental Death Program and/or Firefighters Coverage (PORS)
- 6503external link, opens in a new tab Electronic Employer Services (EES) Employer Confidentiality Agreement
- 6504external link, opens in a new tab Electronic Employer Services (EES) Authorizing Contact Designation/Agreement
- 6505external link, opens in a new tab Electronic Employer Services (EES) Designated Agent Confidentiality Agreement
7000 Series
- 7201external link, opens in a new tab Retired Member Change of Beneficiary (South Carolina Retirement System, Police Officers Retirement System)
- 7201Gexternal link, opens in a new tab Retired Member Change of Beneficiary Form (GARS)
- 7202external link, opens in a new tab Withholding Certificate for Monthly Benefit Payments
- 7204external link, opens in a new tab Direct Deposit Authorization
- 7213external link, opens in a new tab Authorized Representative Form
- 7214external link, opens in a new tab School Resource Officer Critical Needs Certification
- 7216external link, opens in a new tab COVID-19 Earnings Limitation Exception Certification
- 7217external link, opens in a new tab Termination of Retired Member Working Under Earnings Limit
- 7218external link, opens in a new tab 12-Month Break-in-Service Exemption Certification
- 7500external link, opens in a new tab Teacher and Employee Retention Incentive (TERI) Payout Election Form
- 7700external link, opens in a new tab Deduction Form, Public Safety Officer Insurance Payment Program - EIP Only
- 7701external link, opens in a new tab Deduction Form, Public Safety Officer Insurance Payment Program - Non-EIP
- 7800external link, opens in a new tab Deferred benefit Account (JSRS) Payout Form
Death
- Refund Request (South Carolina Retirement System, Police Officers Retirement System)external link, opens in a new tab
- Certification of Nonexistent Trust (All Systems)external link, opens in a new tab
- Application to Append Coverage for Incidental Death Benefit (SCRS)external link, opens in a new tab
- Application to Append Coverage for Incidental Death Benefit, Accidental Death Program and/or Firefighters Coverage (PORS)external link, opens in a new tab
- Withholding Certificate for Monthly Benefit Paymentsexternal link, opens in a new tab
Employer
- Employer Certification of Police Officers Retirement System (PORS) Eligibilityexternal link, opens in a new tab
- Standard Retirement Quarterly Report (South Carolina Retirement System, Police Officers Retirement System)external link, opens in a new tab
- Standard Retirement Quarterly Report - Class I Employer (South Carolina Retirement System, Police Officers Retirement System)external link, opens in a new tab
- Adjustment to Quarterly Payroll Report (South Carolina Retirement System, Police Officers Retirement System)external link, opens in a new tab
- Supplemental Service Report (South Carolina Retirement System, Police Officers Retirement System)external link, opens in a new tab
- ACH Debit Authorizationexternal link, opens in a new tab
- Supplemental Contribution Reportexternal link, opens in a new tab
- Fiscal Year Contribution Ratesexternal link, opens in a new tab
- Due Date Calendarexternal link, opens in a new tab
- Service Purchase Salary Verificationexternal link, opens in a new tab
- Employer Resolution on Tax Deferred Payroll Deductions for Installment Purchaseexternal link, opens in a new tab
- Employer's Disability Employment Status Reportexternal link, opens in a new tab
- Employer Eligibility Determination Requestexternal link, opens in a new tab
- Employer Resolution and Application (SCRS)external link, opens in a new tab
- Employer Resolution and Application (PORS)external link, opens in a new tab
- Electronic Employer Services (EES) Employer Confidentiality Agreementexternal link, opens in a new tab
- Electronic Employer Services (EES) Authorizing Contact Designation/Agreementexternal link, opens in a new tab
- Electronic Employer Services (EES) Designated Agent Confidentiality Agreementexternal link, opens in a new tab
- Electronic Employer Services (EES) Payment Authorization Agreementexternal link, opens in a new tab
- Deduction Form, Public Safety Officer Insurance Payment Program - EIP Onlyexternal link, opens in a new tab
- Deduction Form, Public Safety Officer Insurance Payment Program - Non-EIPexternal link, opens in a new tab
- COVID-19 Earnings Limitation Exception Certificationexternal link, opens in a new tab
- Termination of Retired Member Working Under Earnings Limitexternal link, opens in a new tab
Enrollment
- Enrollment Form (All Systems)external link, opens in a new tab
- Beneficiary Form - Beneficiary Designation, Contingent Beneficiary (All Systems)external link, opens in a new tab
- Beneficiary/Trustee Designation Form (All Systems)external link, opens in a new tab
- Election of Non-Membershipexternal link, opens in a new tab
- State Optional Retirement Program (ORP) Active Incidental Death Benefit Beneficiary Form (South Carolina Retirement System)external link, opens in a new tab
- Certification of Trust (All Systems)external link, opens in a new tab
GARS
- Name/Address Change Formexternal link, opens in a new tab
- General Assembly Retirement System Special Contributing Member Electionexternal link, opens in a new tab
- General Assembly Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
- Direct Deposit Authorizationexternal link, opens in a new tab
Installment
- Requirements for a Participant to Revoke Election to Participateexternal link, opens in a new tab
- Installment Service Purchase Remittanceexternal link, opens in a new tab
JSRS
- Name/Address Change Formexternal link, opens in a new tab
- Judges and Solicitors' Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
- Deferred benefit Account (JSRS) Payout Formexternal link, opens in a new tab
Leaving covered employment
PORS
- Employer Certification of Police Officers Retirement System (PORS) Eligibilityexternal link, opens in a new tab
- Name/Address Change Formexternal link, opens in a new tab
- Fiscal Year Contribution Ratesexternal link, opens in a new tab
- Police Officers Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
- Police Officers Retirement System Application for Disability Retirementexternal link, opens in a new tab
- Member's Disability Reportexternal link, opens in a new tab
- Employer's Description of Disability Applicant's Jobexternal link, opens in a new tab
- Authorization for Release of informationexternal link, opens in a new tab
- School Resource Officer Critical Needsexternal link, opens in a new tab
- Employer Resolution And Application (PORS)external link, opens in a new tab
- Application to Append Coverage for Incidental Death Benefit, Accidental Death Program and/or Firefights Coverage (PORS)external link, opens in a new tab
- Direct Deposit Authorizationexternal link, opens in a new tab
- 12-Month Break-in-Service Exemption Certificationexternal link, opens in a new tab
Public safety
- Deduction Form, Public Safety Officer Insurance Payment Program - EIP Onlyexternal link, opens in a new tab
- Deduction Form, Public Safety Officer Insurance Payment Program - Non-EIPexternal link, opens in a new tab
Refund
Retirement - disability
- Police Officers Retirement System Application for Disability Retirementexternal link, opens in a new tab
- South Carolina Retirement System Application for Disability Retirementexternal link, opens in a new tab
- Employer's Disability Employment Status Reportexternal link, opens in a new tab
- Administrative Appeal Disability Reportexternal link, opens in a new tab
- Retiring Member's Disability Applications Checklistexternal link, opens in a new tab
- Direct Deposit Authorizationexternal link, opens in a new tab
Retirement - service
- General Assembly Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
- Judges and Solicitors' Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
- SCNG Service Retirement Applicationexternal link, opens in a new tab
- Police Officers Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
- South Carolina Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
- Retiring Member's Service Application Checklistexternal link, opens in a new tab
- Withholding Certificate for Monthly Benefit Paymentsexternal link, opens in a new tab
- Direct Deposit Authorizationexternal link, opens in a new tab
SCRS
- Name/Address Change Formexternal link, opens in a new tab
- Fiscal Year Contribution Ratesexternal link, opens in a new tab
- South Carolina Retirement System Application for Service Retirement Benefitsexternal link, opens in a new tab
- South Carolina Retirement System Application for Disability Retirementexternal link, opens in a new tab
- Employer Resolution and Application (SCRS)external link, opens in a new tab
- Application to Append Coverage for Incidental Death Benefits (SCRS)external link, opens in a new tab
- Direct Deposit Authorizationexternal link, opens in a new tab
- Teacher and Employee Retention Incentive (TERI) Payout Election Formexternal link, opens in a new tab
- 12-Month Break-in-Service Exemption Certificationexternal link, opens in a new tab
Service purchase
- Request for Service Purchase Cost (All Systems)external link, opens in a new tab
- Request for Public/Educational Service Verificationexternal link, opens in a new tab
- Request for ORP Service Verification (Applies to ORP service in South Carolina only)external link, opens in a new tab
- General Assembly Retirement System Special Contributing Member Electionexternal link, opens in a new tab
- Service Purchase Salary Verificationexternal link, opens in a new tab
- Service Purchase Payment Options (All Systems)external link, opens in a new tab
- Service Purchase Federal Address Listexternal link, opens in a new tab
- Requirements for a participant to Revoke Election to Participateexternal link, opens in a new tab
- Installment Service Purchase Remittanceexternal link, opens in a new tab
State ORP
- Election of Non-Membershipexternal link, opens in a new tab
- State Optional Retirement Program (ORP) Active Incidental Death Benefit Beneficiary Form (South Carolina Retirement System)external link, opens in a new tab
- Name/Address Change Formexternal link, opens in a new tab
- State Optional Retirement Program (State ORP) Notice of Termination or Changeexternal link, opens in a new tab
- Fiscal Year Contribution Ratesexternal link, opens in a new tab
- Request for ORP Service Verification (Applies to ORP service in South Carolina only)external link, opens in a new tab