Forms

        Common Law Marriage Affidavit  
                Used to certify a relationship as a common law marriage.

        Termination Notification Form  
                Used for notification of an employee, spouse or dependent's coverage termination.

        Name and/or Address Change Notification Form  
                Used for notification of a name and/or address change.

        Life Beneficiary Change Form  
                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) Authorization Change Form  
                Used to change or update the person(s) to whom Protected Health Information can be released.

        Child Other Than Own Form  
                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  
                Used when enrolling an eligible disabled child aged 26 years or older.

        Dental Claim Reimbursement Form  
                Used to file for reimbursement of out-of-network services when the provider will not file the claim.

        Medical Claim Reimbursement Form  
                Used to file for reimbursement of out-of-network services when the provider will not file the claim.

        Prescription Mail Order Form  
                Used for setting up a prescription for mail order delivery.

        Vision Claim Reimbursement Form  
                Used to file for reimbursement of out-of-network services when the provider will not file the claim.

        Child Deductible Reimbursement Form  
                Used for reimbursement of child deductible amounts over 50%.

        Dependent Accident Reimbursement Form  
                Use for reimbursement of child accidental injury amounts paid out-of-pocket up to $500.

        Employee Class Form  
                Used for defining what benefits each type of employee can enroll in.