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  1. Home
  2. City Departments
  3. Human Resources
  4. Benefits
  5. Benefits Information
  6. Benefits Forms

Benefits Forms

All forms must be completed and returned to Human Resources for processing.
  • Benefit Enrollment/Change Form
  • Public Benefit Dependent Affidavit Form
  • Domestic Partner Affidavit
  • Standard Life Insurance Company Enrollment/Change Form
  • Standard Statement of Health (SOH) Form
  • Medical Opt-Out/Right of Refusal
  • FSA Enrollment and FSA Orthodontia
  • Nationwide Online Enrollment/Change Instructions
  • Nationwide 401(a) ASRA Supplemental Retirement Savings Agreement
  • Nationwide 401(a) ASRS Graded Contribution Schedule
  • Metlife Voluntary Insurance Enrollment Form
  • Metlife Statement of Health (SOH)
  • Metlife Calculation Sheet
  • AFLAC - Please contact AFLAC Representative

Beneficiary Change Forms

  • ASRS - Online Only
  • PSPRS
  • Nationwide - Online Only
  • Metlife
  • Standard

Notify Me

Contact Us

  1. Human Resources

    Email the Department

    Physical Address
    16000 N Civic Center Plaza
    Surprise, AZ 85374


    16000 N Civic Center Plaza Surprise AZ 85374
    Directions

    Phone: 623.222.3500
    Fax: 623.222.3501

    TTY: 623.222.1002

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Public Notice:
    • Notice of Ground Ambulance Rate Increase
    • Notice of Surplus Property Online Auction
    • REQUEST FOR ARGUMENTS FOR AND AGAINST THE AUTHORIZATION OF SALE AND ISSUANCE OF BONDS PAYABLE FROM A SECONDARY (AD VALOREM) PROPERTY TAX BY THE CITY TO BE CONSIDERED BY THE VOTERS OF THE CITY OF SURPRISE, ARIZONA, AT AN ELECTION TO BE HELD ON NOVEMBER 7, 2017
    • Notice of Intent for New or Revised Community Development Fees

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  1. 16000 N Civic Center Plaza    Surprise, AZ 85374    City Hall Hours: Monday - Friday; 8 a.m. - 5 p.m.
  2. Phone: 623-222-1000  |  TTY: 623-222-1002  |  Phone Directory | Privacy Statement | Accessibility | Copyright Notices | Government Websites by CivicPlus®