Additional settings for Safari Browser.
Forms
Forms
-
- Code Correction Form (updated 10/22/2021)
- Deposit Correction Form (updated 4/14/2021)
- Interdepartmental Transfer
- Intouch Revised Deposit Form (updated 10/14/2020)
- Waived Fee Form
-
- Claim Forms & Instructions
- Forms and Instructions for Name and Beneficiary Changes
- Other Forms
- Health Insurance Forms
- HIPAA
- Benefit Change Form
- Benefit Change Form
- Complete this form to make an Approved Section 125 Change to your benefits.
- Birth or Adoption of a child
- Marriage or Divorce that results in loss of other coverage
- Court Ordered coverage
- Death of spouse or dependent
- Involuntary loss of coverage
- Employee or dependent gains coverage elsewhere
- Change in dependent status
- Payroll change is effective 1st of the month following the request is received in the Benefits Office.
- You must COMPLETE and submit all forms and documentation within 31 days of the event in order to make changes.
- Mesquite ISD Cancellation Request
- Mesquite ISD Cancellation Request Form
- Complete this form to stop your
- Annuity (403b, 457) contribution
- Lone Star 529 Plan contribution
- Auto/Homeowners insurance
- Accident Insurance
- Critical Illness insurance
- Accidental Death and Dismemberment insurance
- Texas Life Permanent Life insurance
- Standard Term Life insurance policy
- Payroll change is effective 1st of month following date request is received in Benefits Office.
- The Standard Insurance Forms
- Medical History Statement
- Complete this form if you wish to obtain or increase life insurance coverage during a benefits open enrollment opportunity.
- Select your State of Residence and Language Preference (English or Spanish).
- Name of Group: Mesquite ISD
- Group Number: 648015
- Type of Application:
- Initial (DO NOT SELECT THIS OPTION during an open enrollment opportunity; this option is for NEW HIRE enrollment)
- Increase in Coverage (if you are increasing your current life insurance amount more than $10k or over Guarantee Issue Amount)
- Late Application (if this is your initial enrollment for life insurance)
- Continued Dependent Life Insurance for a Disabled Child
- If you are applying for dental, vision or life coverage for disabled dependent over age 26, this form must be completed and submitted within 31 days from the dependent’s coverage end date.
-
-
-
Leave of Absence
A leave of absence request must be completed if an employee will be absent for six or more consecutive days. The request for a leave of absence should be completed and submitted using the Mesquite ISD Request for Leave form.
A physician’s statement is required for leave approval. You may upload the documentation in the google form request or email or fax a copy of your physician's statement to Brenda Barron in Personnel Services.
Email: BBarron@mesquiteisd.org
Fax: 972-882-7799*Your leave request will NOT be approved until you have submitted your physician's statement.
-
-
- Authorization to Transport Students in Private (added 4/29)
- Employee Acknowledgement Form – English (updated 8/25)
- Employee Acknowledgement Form - Spanish (updated 8/25)
- First Report of Injury – English (updated 8/25)
- First Report of Injury – Spanish (updated 8/25)
- Employee/Witness Written Statement – English (updated 8/25)
- Employee/Witness Written Statement – Spanish (updated 8/25)
- Work Injuries and How to Report Them (added 7/24)
- Vehicle Accident Report (Updated 10/22)
- OPTUM First Fill Prescription Card – English and Spanish (updated 8/25)
-
-
Should a Sick Leave Bank (SLB) member have an eligible medical event, the application and request process must be completed at least ten (10) calendar days prior.
An unanticipated medical event application and request process must be completed within ten days after the qualifying emergency.
All three required documents must be submitted to the Personnel Office within this ten-day period without exception.
After your Physician completes the Physician's Statement Form and you fill out the SLB request form, you must bring both forms to the Personnel Office and fill out a HIPPA Authorization for Release form.
Catastrophic illness or injury is a severe condition or combination of conditions affecting the mental or physical health of the employee that requires the services of a licensed practitioner for a prolonged period of time and that forces the employee to exhaust all leave time earned by that employee and to lose compensation from the district. Such conditions typically require prolonged hospitalization or recovery or are expected to result in disability or death. Conditions related to pregnancy or childbirth shall be considered catastrophic if they meet the requirements of this paragraph.
-