[City of Shreveport] Benefits Change Request

The Benefits Enrollment Change Request form requires City of Shreveport Employees to upload copies of required documents for each type of change. A valid email address is required to submit this form.

Employee Name Change:
- State Photo ID
- Marriage License
- Judgment of Diviorce
- Legal Name Change

Phone Number, Email Address or Physical Address
- State Photo ID

Please have the necessary copies as you proceed. Missing documentation will cause delays or denials in processing your change request.

Please check that you agree before continuing.

By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored. By selecting the "Submit & Sign" button, you are confirming that you are the City of Shreveport employee or their legal representative authorized to submit this change request to personal data in the City's payroll and/or insurance systems. By selecting the "Sign & Submit button you agree your electronic Signature is the legal equivalent of your manual/handwritten signature on this change request form.

Create Your Signature

Please fill in your name and email and then either draw or type your signature below.

Full Legal Name

Your Initials

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Type Draw Upload Custom

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

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Employee
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Benefits Division

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Employee Name Change:

Phone Number, Email Address or Physical Address

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