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 |