Forms

Common Law Marriage Affidavit
》Used to certify a relationship as Common Law Marriage
Download
Termination Notice
》Used to Notify the Health Plan Administration Office of an Employee, Spouse or Dependent's Health Plan Termination
Download
Name & Address Change
》For any employee to use at any time to notify the Health Plan of a name or address change
Download
Life Beneficiary Change
》For employees to use at any time to change or add a beneficiary for their Group Life Coverage and/or their Additional Life Coverage
》A beneficiary is the individual who would receive the life insurance benefit if the employee should pass away
》Multiple beneficiaries can be listed (both primary and secondary)
Download
Life Conversion
》For applying for Conversion of Life Insurance Coverage into an individual policy upon termination of or involuntary reduction in Life Insurance Coverage
Download
Life Portability
》For applying for Portability of Life Insurance Coverage into an individual policy upon termination of or involuntary reduction in Life Insurance Coverage
Download
Private Health Information (PHI) Release Authorization Change
》For employees to use at any time to change or update the person(s) to whom they want the plan to release Protected Health Information
Download
Dependent Other Than Own
》For employees to use when enrolling a dependent that is not their own, but yet for which they are legally responsible and can supply the Plan with supporting documentation of such
Download
Disabled Dependent
》For employees to use when enrolling an eligible disabled dependent that is over the Health Plan’s dependent child age limit of 26 years old
Download
Additional Life Coverage Worksheet
》For employees to use during initial enrollment, Open Enrollment, or during a Special Election Period to select additional term life coverage for themselves, their spouses and/or dependent children
》This worksheet allows employees to know how much they can qualify for and how much it will cost
Download
Dental Claim Reimbursement
》Use this form for reimbursement of an out-of-network dental provider visit where the provider will not file the claim on your behalf
Download
Medical Claim Reimbursement
》Use this form for reimbursement of an out-of-network medical provider visit where the provider will not file the claim on your behalf
Download
Prescription Mail Order
》Use this form for setting up a prescription for mailorder delivery
Download
Vision Claim Reimbursement
》Use this form for reimbursement of an out-of-network vision provider visit where the provider will not file the claim on your behalf
Download
Dependent Deductible Reimbursement
》Use this form for reimbursement of Dependent Deductible amounts paid out-of-pocket over 50% per child per plan year
Download
Dependent Accident Reimbursement
》Use this form for reimbursement of Dependent Accidental Injury claim amounts paid out-of-pocket up to $500 per child per plan year
Download