Below are forms and information sheets for Luzerne County Employees. 

Please click on the desired form or information sheets, fill out the form, print and sign and hand back into Human Resources. (remember to print copy for yourself) 

New Employee Information for Department Admin: (for new hires, changes, etc.)

• Required Paperwork for New Employee
• 2010 W4 Form
• Form I-9, Employment Eligibility Verification Form
• New Employee Information Sheet
• Long Sheet Information for Payroll
• Authorization for Background Check Form
• Loyalty Oath
• Notice of Separation Form
• Request for Leave Form
• Personnel Policy Information
• Personnel Policy Acknowledgement Letter
• Liberal Leave Policy
• Direct Deposit Enrollment Form
• Smoke Free Environment Policy
• Substance Abuse Policy
• Sexual Harassment Policy
  • Sample Sexual Harassment Complaint Form
  • Sample Sexual Harassment Witness Form
• Letter of Understanding of Luzerne County Policies Form
• Luzerne County Travel Policy
• Workers Compensation Information Employee Notification Sheet
• Request for Family or Medical Leave
• Mazzitti and Sullivan's Employee Assistance Program Website
• Sick Bank Request Form
• Required Paperwork for Terminated Employees

Employee Health Care Information:

• Blue Cross/First Priority Enrollment Application/Change Form for Group Coverage
  • Blue Cross Health Insurance Supplemental Form
• Geisinger Health Options Enrollment Form
• Luzerne County Courthouse Health Insurance Form
• Health Insurance Waiver Form 2010 
• Direct Remibursement Claim Form - Davis Vision
  • Fashion Excellence Option 1 Benefits Summary
• Delta Dental Enrollment/Change Form
  • Delta Dental Highlight Sheet
  • 2010 Dental Rates
• Life Insurance Form
  • Example Life Insurance Form 

Employee Workers Compensation Information:

• Instructions for completing Workers Comp. Accident and Injury Report
• Accident Investigation and Accident Reporting
  • Accident Injury Reporting Form
  • SAMPLE Accident Injury Reporting Form
  • Accident Investigation & Corrective Action Reporting Form

 Employee Retirement System:

• Luzerne County Employees Retirement System Information
  • Form 1 Enrollment Form
  • Form 2 Information Change Request
  • Form 3 Request to Purchase Prior Service
  • Form 4 Preliminary Quote Request
  • Form 5 Notification Letter of Intent to Terminate and/or Retire
  • Form 6 Notice of Termination and/or Retirement
  • Form 7 Participant Death Notice
  • Form 8 Beneficiary Death Notice
  • Form 9 Retirement Definitions
  • Form 10 Explanation of Retirement Options
  • Form 11 Retirement Information Change
  • Direct Deposit Form for Retirement System
  • Disability Retirement Form 
• Luzerne County 457 Deferred Compensation Plan Information

*Note: More forms and information will be posted soon.