Forms

Quick Links:
» Enrollment
» Termination Notice
» Name & Change
» Life Beneficiary Change
» PHI Authorization Change
» Dependent Other Than Own
» Dependent With Disabilities
» Additional Dependents
» Additional Life Coverage Worksheet
» Additional Life Health Assessment
» Dental Claim Reimbursement
» Medical Claim Reimbursement
» Prescription Mail Order
» Vision Claim Reimbursement
» Life Insurance Portability & Conversion
» Dependent Deductible Reimbursement
» Dependent Accident Reimbursement
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Enrollment Form

Form: Enrollment.pdf

» All New Enrollments should be conducted through the Health Plan's HEART Platform. Click Here to access the HEART platform.
» Do Not Use this form to enroll onto the Health Plan unless expressly directed to do so by the Health Plan's Administration Office.
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Common Law Marriage Affidavit

Form: Common Law Marriage Affidavit.pdf

» Used to certify a relationship as a Common Law Marriage.
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Termination Notice

Form: Termination Notice.pdf

» Used to Notify the Health Plan Administration Office of an Employee, Spouse or Dependent's Health Plan Termination.
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Name & Address Change

Form: Name Address Change.pdf

» For any employee to use at any time to notify the Health Plan of a name or address change.
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Life Beneficiary Change

Form: Life - Beneficiary Change.pdf

» 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 one who would receive the life insurance benefit if the employee should pass away. Multiple beneficiaries can be listed (both primary and secondary).
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PHI Authorization Change

Form: PHI Release Authorization.pdf

» 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.
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Dependent Other Than Own

Form: Dependent Child Other Than Own.pdf

» 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. This form should accompany the Employee Enrollment Form.
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Dependent With Disabilities

Form: Dependent with Disabilities.pdf

» For employees to use when enrolling an eligible disabled dependent that is over the Health Plan’s dependent child age limit. This form should accompany the Employee Enrollment Form.
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Additional Dependents

Form: Additional Dependents.pdf

» For employees to use when completing the Employee Enrollment Form and they need additional space to list dependents.
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Additional Life Coverage Worksheet

Form: Additional Life Worksheet.pdf

» 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 lets them know how much they can qualify for and how much it will cost.
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Additional Life Health Assessment

Form: Life - Health Assessment.pdf

» For employees and spouses to use when applying for Additional Life Coverage outside of their initial offering period. Dearborn National uses this Health questionnaire to determine insurability.
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Dental Claim Reimbursement

Form: Dental Claim Reimbursement.pdf

» Use this form for reimbursement of an out-of-network dental provider visit where the provider will not file the claim on your behalf.
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Medical Claim Reimbursement

Form: Medical Claim Reimbursement.pdf

» Use this form for reimbursement of an out-of-network medical provider visit where the provider will not file the claim on your behalf.
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Prescription Mail Order

Form: Prescription Mail Order.pdf

» Use this form for setting up a prescription for mailorder delivery.
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Vision Claim Reimbursement

Form: Vision Claim Reimbursement.pdf

» Use this form for reimbursement of an out-of-network vision doctor visit where the provider will not file the claim on your behalf.
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Life Insurance Portability & Conversion

Form: Life - Portability Application.pdf
Form: Life - Port vs Conversion.pdf
Form: Life - Conversion Application.pdf

» The following documents are to aid members and spouses when applying for life insurance portability or conversion upon termination from the Health Plan.
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Dependent Deductible Reimbursement

Form: Dependent Deductible Reimbursement.pdf

» Use this form for reimbursement of Dependent Deductible amounts paid out-of-pocket over $375 per child per plan year.
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Dependent Accident Reimbursement

Form: Dependent Accident Reimbursement.pdf

» Use this form for reimbursement of Dependent Accidental Injury claim amounts paid out-of-pocket up to $500 per child per plan year.
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