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Employee Forms & Resources

Employee Forms & Resources

Benefits
Dental & Vision
Retirement & Retirees
Mental Health

Benefits

Insurance

Cobra - Health Insurance Continuation Coverage (PDF)

Employee Assistance Program

Help Line (Toll-Free) 1-866-327-2400
Email Deer Oaks
Monthly Employee Newsletter (PDF)
Monthly Supervisor Newsletter (PDF)
Work Life Childcare (PDF)
Work Life Services (PDF)
Life Coaching (PDF)

American Fidelity

2023-2024 Employee Benefits Guide (PDF)
Enrollment Website
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CareFirst Blue Cross / Blue Shield

Allegany County Medicare Part D Creditable Coverage
CVS/Caremark Reimbursement Form (PDF)
CVS/Caremark Mail Order Form (PDF)
Active Employees: Preferred Provider Organization (PDF)
Benefits Summary (PDF)
Health Benefit Options (PDF)
CareFirst Website
CareFirst Wellness program available through Sharecare on the CareFirst website
Scale Back Lifestyle Change Program Flier (PDF)

Flexible Spending Program*

Flexible Spending Account Brochure (PDF)
Dependent Care Flexible Spending Account (PDF)
OTC Drugs and Medicines Eligible with a Doctor’s Prescription (PDF)
Online Administration
FSA Claim Form (PDF)

Life Insurance & Supplemental Insurance

Aflac
Loyal American Early Detection Benefit Claim Form (PDF)
Metlife Beneficiary Form (PDF)

Dental & Vision

Dental Benefits thru Dominion National (effective 2.1.18)

Dominion Benefits and Member Copayments (PDF)
Dominion Enrollment Form and Signature Card (PDF)
Dominion Monthly Rates (PDF)
Dominion Overview (PDF)

Vision Benefits America
https://www.vbaplans.com/vision

VBA 1160 Allegany County information Coverage (PDF)
Vision Benefits of America Brochure (PDF)
Vision Benefits of America Coverage Information (PDF)

BlueDental Plus (effective 7.1.2018)

BlueDental Plus Plan 4 - MD Employer Sponsored - No Ortho Fact Sheet (PDF)
Carefirst Dental Rates Allegany County (PDF)
Dental Benefits - Services Breakdown (PDF)

Retirement & Retirees

General Forms

Retiree Address and Telephone Update Form (PDF)
Retiree with Medicare Address and Telephone Update Form (PDF)

Deferred Compensation

Website: Nationwide Retirement Solutions
Nationwide Retirement Solutions: Payroll Authorization Card (PDF)
Nationwide Retirement Solutions: Schedule an Appointment
Website: Valic -AIG Retirement

CareFirst Blue Cross / Blue Shield Benefit Guides

Allegany County Medicare Part D Creditable Coverage
Preferred Provider Organization - Retiree Under 65 (PDF)
Benefit Summary (PDF)
Health Benefit Options (PDF)

One Exchange Information for Retirees with Medicare

(HRA: Health Reimbursement Act)

Direct Deposit Form (PDF)
Newsletter (PDF)
Recurring Premium Reimbursement Form (PDF)

State of Maryland Retirement and Pension System

Newsletter (PDF)
State of Maryland Retirement and Pension Website

Mental Health

CareFirst Behavioral Health Digital Resource Member FAQs
CareFirst Behavioral Health Digital Resource Member Flier
CareFirst Behavioral Health Digital Resource Member Getting Started Guide

Employee Discount OPtions

US Cellular Employee Discount (PDF)

Human Resources
Finance
Holiday Schedule

Human Resources

Contact & Leave Forms

Personal Information Update Form (PDF)
Change of Address Form (PDF)
FMLA: Certification of Health Care Provider (PDF)
Leave Request Form (PDF)
Leave of Absence Form (PDF)

Employment Forms

Application (PDF)
Background Check Release Form (PDF)
Disclosure Authorization and Release (PDF)
Employment Eligibility Verification Form (I9) (PDF)
Grievance (PDF)
Incident Report (PDF)

Personnel Action Forms (Supervisors)

Request for Personnel Action (PDF)
Request to Fill Vacancy (PDF)

Finance

Payroll and Tax Forms

Authorization for Automatic Deposit (PDF)
Change of Address Form (PDF)
W-4 (Federal Income Tax Withholding Form (PDF))
Employee's Maryland Withholding Exemption Certificate (PDF)
WV Employee's Withholding Exemption Certificate (PDF)
WV Certificate of Non-Residence (PDF)
W9 - Request for Taxpayer ID Number & Certification (PDF)

Travel and Expense Forms

Expense Report Form (PDF)
Mileage Voucher
Request for Travel Approval (PDF)
Request for Reimbursement Form (PDF)

Holiday Schedule

Civil Service Holiday Schedule

Employee Rules & Regulations (PDF)
Pay Range (PDF)
IT Work Order Request
Technology Use Policy (PDF)
FCC Title 47 Rules & Regulations
VBA Portal

Tax & Utility Office

Transparency Portal

Sheriff's Office

Detention Center

Recycling & Landfill

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701 Kelly Road Cumberland, MD 21502

Phone: 301-777-2526

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Available Jobs with Allegany County

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