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Health, Dental & Vision Insurance Forms

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  1. Register for open enrollment webinar

  2. Health Benefits

  3. Dental/Vision Benefits

  4. Flexible Spending Account

  5. Life Insurance

  6. Orientation Forms

  7. Legal plan benefit

Contact Us

  1. Finance

    Physical Address
    22 Lincoln Street
    7th Floor, Finance Dept.
    Hampton, VA 23669

    Phone: 757-727-6230
    Fax: 757-727-6262

  1. Register for open enrollment webinar
  2. Health Benefits
    1. City Manager's Memo to City Employees
    2. Health Benefit Election Form (PDF)
    3. Health Insurance Enrollment Application (PDF)
    4. Health Insurance Premiums (PDF)
    5. Health Insurance Benefit Summary (PDF)
    6. Optima Preventive Care Services (PDF)
    7. Premium Assistance (PDF)
    8. OptumRx - Select Standard Formulary (PDF)
    9. Waiver of Group Health Benefits (PDF)
  3. Dental/Vision Benefits
    1. Dental / Vision Benefit Election Form (PDF)
    2. Delta Dental Enrollment Form (PDF)
    3. Dental / Vision Premiums (PDF)
    4. Delta Dental PPO - EPO Summary (PDF)
    5. Delta Dental PPO Plus Premier (PDF)
    6. Delta Dental PPO – EPO Schedule of Benefits (PDF)
    7. EyeMed Enrollment Form (PDF)
    8. EyeMed Vision Care - Summary of Benefits (PDF)
  4. Flexible Spending Account
    1. Flexible Spending Account Election Form (PDF)
    2. Dependent Care Flexible Spending Account (PDF)
    3. Dependent Care Claim Form (PDF)
    4. Healthcare Flexible Spending Account (PDF)
    5. Healthcare Pay Me Back Claim Form (PDF)
    6. EZ Receipts Mobile App (PDF)
    7. FSA Over-the-Counter Drugs and Medicines (PDF)
    8. Orthodontia Payment Guidelines (FSA) (PDF)
  5. Life Insurance
  6. Orientation Forms
  7. Legal plan benefit
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    1. City of Hampton
      22 Lincoln Street
      Hampton, VA 23669

      Phone: 757-727-8311

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