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