Forms

Medical/Dental/Vision - Enrollment Form - Medical Claim - Dental Claim - Affidavit of Dependent Eligibility (Age 19-25) - Affidavit of Dependent Eligibility (Age 25-30) - Affidavit of Grandchild Eligibility - Affidavit of Dependent Permanent Disability - Prescription Drug Claim - Aetna Home Delivery	HR Forms - Change of Name/Address - Outside Employment - Direct Deposit Enrollment (Payroll) - Direct Deposit Cancel (Payroll) - 2009 W4 - Pretax Premium DROP Form
Tuition Reimbursement  - Education Reimbursement - (EMS Union Contract Employees Only) Education Reimbursement	Long & Short-Term Disability - Contact the Benefits Dept 239-533-2363
Deferred Compensation: ICMA 457 Forms Employee Enrollment Form Employee Enrollment Form (Spanish) Change Form Catch-Up Provision Packet Account Transfer Packet 30 Day Waiting Period Notice Tax Notice Direct Deposit Form	Leave Requests - Request for Family or Medical Leave (FMLA) - Non-FMLA Leave Request
Flexible Spending Accounts  - FSA Enrollment - FSA Healthcare Reimbursement - FSA Dependent Care Reimbursement - FSA Over-the-Counter Drug Reimbursement   (FSA Control Number 881674)	Minnesota Life  - Enrollment Form - Evidence of Insurability (EOI) Form - Beneficiary Designee

 

Lee County Human Resources

2115 Second Street, First Floor 

Fort Myers, FL 33901-0398

239-533-2245