| Forms |
| 》Common Law Marriage Affidavit PDF |
| Used to certify a relationship as a common law marriage |
| 》Termination Notification Form PDF |
| For notification of an employee, spouse or dependent's coverage termination |
| 》Name and/or Address Change Notification Form PDF |
| For notification of a name and/or address change |
| 》Life Beneficiary Change Form PDF |
| For notification of a change in or addition of a new beneficiary for life coverage |
| A beneficiary is the individual who would receive the life insurance benefit if the employee should pass away |
| Multiple primary and/or secondary beneficiaries can be designated |
| 》Private Health Information (PHI) Release Authorization Change Form PDF |
| Used to change or update the person(s) to whom Protected Health Information can be released |
| 》Child Other Than Own Form PDF |
| Used to enroll a child that is not an employees' own |
| Employee must have legally responsible over the child |
| Employee must provide supporting documentation |
| 》Child with a Disbility Form PDF |
| Used when enrolling an eligible disabled child aged 26 years or older |
| 》Dental Claim Reimbursement Form PDF |
| Used to file for reimbursement of out-of-network services when the provider will not file the claim |
| 》Medical Claim Reimbursement Form PDF |
| Used to file for reimbursement of out-of-network services when the provider will not file the claim |
| 》Prescription Mail Order Form PDF |
| Used for setting up a prescription for mail order delivery |
| 》Vision Claim Reimbursement Form PDF |
| Used to file for reimbursement of out-of-network services when the provider will not file the claim |
| 》Child Deductible Reimbursement Form PDF |
| Used for reimbursement of child deductible amounts over 50% |
| 》Dependent Accident Reimbursement Form PDF |
| Use for reimbursement of child accidental injury amounts paid out-of-pocket up to $500 |
| 》Employee Class Form PDF |
| Use for defining what benefits each type of employee can enroll in |