The City Of Lewiston

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Employee Benefit & Accident Forms
General Forms for Employees                                            Accident Forms

    Direct Deposit for Payroll                                                     Employee Accident Report
    Address Change/Emergency Contact
    City Pay - Beneficiary Change                                            Workers Comp Guidelines
    Position Redesignation Questionnaire - reclassification
    Employee Evaluation Form
Employment Forms

    Application for Employment
    Seasonal Application - Rehires only
    PERSI   8-Month Seasonal Hire Certification
    Employment Outside the City of Lewiston

Hiring supervisor - application, W4 and I9 must be submitted together with the status change for all rehires.  Drug screens must occur prior to first day.

FMLA Forms                                                                        Other

    Family Medical Leave Request Form                                           
    Medical Release Information (FMLA)                                         Exit interview
    Attending Physician Form for Employee's Condition
    Attending Physician Form for Family Member's Condition
    Leave Request

Benefit Forms
Application for Short-Term Disability 

            Health & Life Insurance

    Health Insurance Enrollment/Change Form
    Delta Dental Enrollment/Change Form
    Life Insurance Beneficiary Change Form
    PERSI Beneficiary Change Form
    NCPERS Life Insurance Enrollment & Change Form
            HRA VEBA and Flex Plan 
    How to File a Claim Instructions
    HRA VEBA Claims Form
    Plan Information

    Flex Plan- Polestar 2015 Flex Plan/Premium Form 
                     Polestar Benefits Flex Plan Health Care & Dependent Care Reimbursement Form
    Flex Plan- Polestar Online Access Information
            401K & 457 Deferral Forms

    ICMA 457 Deferral
    Nationwide 457 Deferral
    PERSI Choice Deferral 

        Tuition Reimbursement Forms

Tuition Reimbursement Form

(Reminder - Tuition reimbursement is limited to $600 per employee per fiscal year and $100 for books - and approval does not mean full tuition will be reimbursed.  Division of funds will occur upon completion of courses, presentation of receipt for course fees and completed grade.  

Reimbursements will be distributed to those approved applicants in an equitable manner.  The budget is currently $4,000 per fiscal year.)