Salem, Oregon
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Michele Bennett
Human Resources Division Manager
503-589-2077
Carrie Wagner
Employee Benefits Management Analyst
503-589-2085
Will Nixon
Human Resources Specialist
503-763-3447
Employee Benefits Team: benefits@cityofsalem.net
Human Resources Department
295 Church St. SE
Suite 210
Salem, OR 97301
503-588-6162
Hours
Monday – Friday
8:00 a.m. - 5:00 p.m.
Human Resources and Employee Benefit Forms
These are all of the forms that you may need to take advantage of your employee benefits, as well as other helpful Human Resources forms. Find links to detailed information about benefits for your specific employee group from the Jobs page.
2024 Federal W-4 Form- 2024 Oregon W-4 Form
- Birth Certificate Verification Form
- Cigna Pharmacy Claim Form
- Cigna Provider Network Nomination Form
- Cigna Vision Claim Form 2023
- Cigna Vision Claim Form 2024
- Commute Expense Reimbursement Account (CERA) Claim Form
- Commute Expense Reimbursement Account (CERA) Enrollment Form
- Dependent Name Change form
- Disabled Dependent Health Insurance Certification Form
- Domestic Partner Certification for Dependent Tax Status form
- Domestic Partner Health Insurance Affidavit Form
- Domestic Partner Health Insurance Termination Form
- Electronic Disclosure Form
- Employee Address or Emergency Contact Change Form
- Employee Name Change Form
- Flexible Spending Accounts (FSA) Enrollment or Waiver Form 2024
- Flexible Spending Accounts (FSA) Reimbursement Claim Form
- Health Hub Service Agreement Form
- Health Insurance Coordination of Benefits Form
- Health Insurance Enrollment, Waiver, Change Form
- Health Insurance Opt-Out Waiver Incentive Form
- Health Savings Account (HSA) Enrollment Form 2024
- Long Term Disability (LTD) Benefit Claim Packet
- PERS IAP Beneficiary Form
- PERS Tier 1 or Tier 2 Beneficiary Form
- Standard Insurance Life, ADD, LTD, Vol plans Enrollment Beneficiary form
- Voya Deferred Compensation EZ Enrollment Form
- Voya Deferred Compensation Final Paycheck Deferral Form
- Voya Deferred Compensation Holiday Cash Out Deferral Form
- Wellness Committee Supervisor Approval Form