Employee Forms

Press Enter to show all options, press Tab go to next option

Employee Forms

Print out needed forms and give to Human Resources when completed.

-Employee Change Notice Form (Name, Address or Phone Number Change)

-Emergency Notification Form (Emergency Contact Change)

Payroll Forms

Iowa W-4

Federal W-4

-Direct Deposit Form

Leave Form

-Leave Request Form


The Family and Medical Leave Act entitles you, if eligible, to use up to 12 weeks of paid and /or unpaid leave within a 12-month period for birth or adoption of a child, or when a child is placed in your foster care, your serious health condition or serious illness of an immediate family member, family military leave or employees are entitled to 26 weeks of paid and/or unpaid leave within a 12-month period for service member family medical leave.  For more information on FMLA, please contact Human Resources.

-Application for FMLA


-Certification for Employee's Serious Health Condition

-Certification for Family Member's Serious Health Condition

-Certification for Injury or Illness of a Service Member

-Certification for Serious Injury or illness of a Veteran for Military Caregiver Leave

-Certification of Qualifying Exigency for Military Caregiver Leave

Benefit Forms

Human Resources is responsible for maintaining the forms for the administration of the benefits offered to County employees and their families. To find a form click on the links below: All forms must be signed before changes can be made to the employee benefits.  For more benefit information, go to the Employee Benefits tab under Employee Resources.


-Wellmark Enrollment/Change Form 

  • Fill out and submit to HR if there is a change in coverage due to a qualifying event such as marriage, divorce, birth or open enrollment (in June).   

-Add a Dependent Form

  • Fill out and submit to HR if you wish to add a dependent child that requires no change in the contract type. (Example: birth of a newborn if you already have family coverage).

-Consent to Receive Electronic Notices

Claim Forms

-Medical and Vision Claim Form

-BlueDental Claim Form

Prescription Forms 

-Wellmark Prescription Mail Order Form

-Prescription Drug Claim Form

Flexible Spending Accounts

Flex Enrollment Form

Life Insurance

-Reliance Standard Life, AD&D & LTD Enrollment Form

-Beneficiary Designation Change Form



Members frequently request the form listed below. Some forms have an online version that you can fill in from your computer and submit electronically. Check out http://www.ipers.org/members/forms/index.html for additional forms from IPERS.

-IPERS Beneficiary Change Form