Medical, Dental, and Vision Coverage Enrollment Form
If eligible, use this form to enroll in medical, dental and vision coverage. You can also use this form to make changes to your benefits during open enrollment or within 30 days of a qualifying event. If you have experienced a qualifying event and you are making benefit changes due to this qualifying event, you must attach documentation of the qualifying event to the form. This documentation from other employer/agency must include date of event, reason for event, date coverage was impacted, and all persons affected by change. In some cases HR may request additional information.
Non-Tobacco Use Incentive Affidavit
Are you a non-tobacco user? If you answered yes, you can receive $240 into a Health Reimbursement Arrangement account to use for qualified medical expenses such as copays, deductibles, over-the-counter medications, etc. To be eligible, you must be enrolled in one of the Knox County medical plans. Just fill out the Non-Tobacco Use Incentive Affidavit and return to Human Resources during the open enrollment period. If you are just now picking up medical coverage, you are also eligible for this benefit.
Flexible Spending Accounts Enrollment Form
If eligible, use this form at time of hire to enroll in Medical or Dependent Care Flexible Spending Accounts. Both options are offered with an easy to use debit card, MasterCard.
If you have experienced a qualifying event and you are making a change to your FSA plan within 30 days of this qualifying event, documentation of the qualifying event must be attached. This documentation must include date of event, reason for event, date coverage was impacted, and all persons affected by change. In some cases HR may request additional information.
Claim Form Reimbursement – Flexible Spending Accounts
If you are a flexible spending account member and are unable to use your debit card for an expense you may pay out of your pocket and then submit a claim for reimbursement.
(Click here to print the Flex Claim Form)
Court South Fitness Club Membership Agreement through Payroll Deduction
If you are a new hire or newly eligible for a membership through payroll deduction use this form to enroll in Court South Fitness Center’s VIP membership through Knox County. Dues will be payroll deducted. Eligibility questions? Contact us at wellness@knoxcounty.org
If you have asked Knox County Human Resources to help you with a claim issue or health related benefits issue we may need this form filled out. If we request you to fill out this form, you may fax this form back to a secure fax number: 865.215.2474 or bring this form back to Suite 360.
Security Benefits 457 Plan Enrollment/Change Form
If you are eligible to participate in this program, please use this form to make your election. If you already participate in the program, please use the form to make the changes you desire.
Who do I turn forms in to? All forms should be returned directly to:
Knox County Human Resources
Attn: BENEFITS STAFF
Suite 360, City County Building
400 Main Street
Knoxville, TN 37902-2405
Questions about forms?
Email us at benefits@knoxcounty.org or call 215-2321
Retirement & Pension Board Forms
Life Insurance, 401A plan, Medical Expense Retirement Forms, and other retirement related forms can be found on the Retirement link www.knoxcounty.org/retirement
