Forms - Mesquite ISD 2022

Complete this form to stop your
- annuity (403b, 457) contribution
- Lone Star 529 Plan contribution
- CHUBB Lifetime Benefit Term policy
- Fidelity Life Insurance policy
- Standard Bundler policy (Accident/Critical Illness)
- Standard Term Life Insurance policy
Payroll change is effective 1^st 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.

Important note: you must have Adobe Acrobat Reader installed on your computer to complete the necessary digital signatures on this form. Adobe Acrobat and Ereader will not support the digital signature. You will not be able to complete the signature portion on the document without Adobe Acrobat Reader.

This document must be completed and submitted electronically. You may not print and scan the document. If you do not have Adobe Acrobat Reader you will need to submit a request to install the program to help desk.

This form is NO LONGER for any type of employee separation. See above for new Employee Separation Form.

It is also NOT for Name Changes – use this form for name changes.

Download and Save the form to your desktop or preferred folder
Open the form in Adobe Acrobat Reader
Complete all the blue fields at the top of the form and make sure you complete the "Replaces" and "Effective Date of Change" fields. Pink fields are optional. All YELLOW and GREEN Fields are for Personnel use ONLY. Employee Signature is optional. Supervisor Digital Signature is REQUIRED.
Once the form is complete and digital signature is added, save the form to your desktop or preferred folder as: "employeename_StatusChangeForm_date"

5. EMAIL the form to the appropriate personnel director:

Paraprofessionals - Kellie Haddock
Elementary Professionals - Larry Sanford
Secondary Professionals - Emilio Duran
Auxiliary - Kyle Holcomb

Click the following button to download the electronic, fillable Employee Status Change Form.

Printable Instructions for
Completing Employee Status Form

Employee Status Change Form

Facilities Rental Forms

Fundraiser Forms

Leave of Absence Forms

Leave of Absence

A leave of absence request must be completed if an employee will be absent for 5 or more consecutive days. The request for a leave of absence should be completed and submitted by using the Mesquite ISD Request for Leave form located on Eduphoria.

Log into Eduphoria.
Select formspace on the left side of the page.
Select Submit New Form in the bottom left corner of the page.
Select Personnel Forms.
Select Leave Request Form and complete the online form.

All Auxiliary employees should request a leave of absence form from their department supervisors, campus administrator or the Auxiliary Personnel department.