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 |