Human Resources

City Employee Links & Forms

457 Programs
2020 IPPFA Compensation Plan 457b-SPD

ADA Reasonable Accommodation Request Form

Dental Insurance
FOC DMO Dental Benefits Summary 2020 876576
FOC PPO Dental Benefits Summary 2020 876576
Aetna Dental Enrollment Change Request Form
Dental Discount Flyer
Dental Enrollment 67971w
Dental Freedom of Choice DMO-PPO Enrollment Brochure
Dental Pilot Over the Counter Brochure
EXPAREL Manage Pain Without Opioids Mbr
Improved Digital Tools Aetna Dental App
Z Dental Plan Sponsor Discount Pricing Structure

Employee Assistance Program

2022 Webinar Schedule
EAP Overview


FMLA Overview
WH-380-E Health Care Provider Employee Serious Health Condition
WH-380-F Health Care Provider Family Member Serious Health Condition

Health Insurance

2022 Health Vision Dental Renewal Rates
Affidavit of Domestic Partnership
City of Berwyn Enrollment Guide 2021
Disabled Dependent Certification Form
Domestic Partnership Termination
Enrollment Change Request Form 22735
Medical Claim Form
Enrollment Form
Nurseline and Virtual Visits Member Flier
Prescription Drug Claim Form
Prescription Prime Mail Form
BCBS HMO Policy Overview
BCBS PPO Policy Overview
BCBS Application and Policy Change
COB Active PPO 55641
COB Retiree PPO 55641
COB HMO 51642


Disability and IMRF Article
Disability Form 540 Members Disability Application
Disability Form 542 Physicians Statement
Disability IMRF Booklet
IMRF Employer Cost and Participation Information
Form 6.93 Certification Of Hours for Elected Official
Form 6.93A-6.21 Certification Of Hours For Elected Officials
Form 603 Application for Reinstatement of Service Credit
Form 620 Change of Information
Form 630 Election to Make Additional Contributions Form
Member Death Form 530 Death Benefit Application
Member Death Form 611 Designation of Beneficiary
Retirement Form 520 Apply for Retirement
Retirement Form 520R Special Needs Annuity Application
Retirement Form 521 Early Retirement Application
Retirement Form 601E Request for Rollover Approval for Early Retirement
Retirement Form 611A Designation of Beneficiary
Retirement Form 710 Health Insurance Continuance Form
Retirement Form 1199 Application for Direct Deposit
Retirement Form BW60 Distribution Rolleover Certification
Retirement Member Checklist 02-2015

Life Insurance

BCBS Term Life Insurance Booklet
2021 Voluntary Benefits Program
IL Beneficiary Designation
Voluntary Group Life and AD&D Primary Rate Grid

Onboarding Documents

2022 Benefits Package
2022 Illinois Withholding Allowance Form
2022 W4 Form
Affidavit of Familial Relationships
Background Check Form
Berwyn Employment Application
Berwyn IMRF Form 610
Blue Cross Blue Shield Enrollment Card
City ID Policy
City of Berwyn Personnel Info Sheet
Direct Deposit Form
Employee Agreement to Social Security Policy
Employee Handbook
Employee ID Sign Off Form
I9 Form
Individual Reporting Form E
Social Security Policy

Police & Fire Pension Forms

New Pensioner Packet Service Retirement
PSEBA Application
PSEBA Recipient Reporting Form

Vision Insurance

VSP Welcome
VSP Member Benefit Summary
Eyeconic Overview with Benefit Integration
VSP Exclusive Member Extras

Worker's Compensation/ Occupational Health

Employer's Authorization Form for Occupational Health
IL Form 45 Employer's First Report of Injury
Map of Directions to Occupational Health
Occupational Health Poster
Worker's Compensation Forms