Forms & Documents
Forms
- Decline Coverage (Opt Out) Election 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.
- Student Dependent Status Form
Complete this form if you have a dependent child ages 19 to 25 who is a full-time student.
- 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.
Documents
Other Documents
- Mail Order Prescription Drug SMM
- Outpatient Lab Services SMM
- Important Notice Regarding Administration of Your HRA Program, Effective March 1, 2010
- Appoint an Authorized Representative Notice (effective 3/1/10)
- Free and Clear SMM
- Preventable Medical Errors and Extension of Student Dependent Coverage
- Important Notice Regarding Your Protected Health Information & Plan’s Claims & Appeals Procedures
