Division of Administrative Services

Division of Administrative Services

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Benefits

Areas of Responsibility:

457 Plan
Change-in-status
Consolidated Public Retirement Board (PERS)
Medical Child Support Orders
Mt. Flex
Public Employees Insurance Agency (PEIA)
Self-Pay
Supplemental Insurance

forms:

DAS Benefits New Hire Checklist

457 Retirement Plus

Mountaineer Flex Benefits Guide

Mountaineer Flex Enrollment Form

PERS Enrollment Form

PERS Application For Refund

PERS Name Change

PERS Pre-Retirement Beneficiary Designation

PERS Authorization to Release Information

PERS Benefit Estimate Request

PERS Combined Living Power of Attorney

PERS Less Than Honorable Service Notification

PERS Living Will

PERS Medical Power of Attorney

PERS Qualified Domestic Relations Order

PERS Application to Purchase Out-of-State Service

PEIA Comprehensive Care Partnership Enrollment Form

PEIA Disabled Dependent Eligibility Application

PEIA Retirement Health Benefits and Basic Life Instructions and Enrollment Form

PEIA Shoppers Guide

PEIA Surviving Dependents Enrollment Form

PEIA MetLife Benefitciary Designation Form

The following 5 forms must be completed online via PEIA website

PEIA Basic Life Enrollment Form

PEIA Change-in-Status Form

PEIA Health Benefit Enrollment Form

PEIA Optional Life

PEIA Policyholder Termination of Coverage Form

RETIREE FORMS:

Mountaineer Flex Benefits Guide (Retiree)

Mountaineer Flex Enrollment Form (Retiree)

PERS Retired Public Safety Officer Authorization For Insurance Premium Deduction

PERS Retired Public Safety Officer Insurance Carrier Agreement

PEIA Retired Employees Optional Life Enrollment Form

Resources:

WV PEIA - https://PEIA.WV.gov

WV Consolidated Public Retirement Board - https://www.wvretirement.com

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