Forms & Documents

Forms

Decline Coverage (Opt Out) Election Form
Appointment of Authorized Representative Form
HIPAA Authorization Form
HRA Claim Form
Subrogation Agreement
Weekly Disability Benefits Claim Form
When applying for Weekly Disability benefits, complete this form.
Vision Claim Form
Complete this form for reimbursement of eye exams.
Proof of Other Insurance Form
Complete this form if you or a dependent has insurance coverage through another plan (e.g., your spouse’s employer).
Life and AD&D Insurance Claim Form
When applying for Life or AD&D insurance benefits, complete this form.
Initial COBRA Notice
Review this form for information about your rights to COBRA Continuation Coverage.
Enrollment Form
Complete this form if you are newly eligible or experience a change in
family status (e.g., marriage or birth of a child).
Beneficiary Designation Form
Use this form to designate or update your beneficiary information.
Contact Lens Order Form
Complete this form when ordering contact lenses.
Dental Claim Form
Complete this form when submitting a dental claim.
Medical Claim Form
Complete this form when submitting a medical claim.