General Forms

 

2018 Employee Enrollment & Change Forms
Group Benefit Enrollment & Change Form | All Lines
Group Benefit Enrollment & Change Form | Non-Medical
Demographic Change Form

 

2017 Employee Enrollment & Change Forms
Group Benefit Enrollment & Change Form | All Lines
Group Benefit Enrollment & Change Form | Non-Medical
Demographic Change Form

 

2016 Employee Enrollment & Change Forms
Group Benefit Enrollment & Change Form | All Lines
Group Benefit Enrollment & Change Form | Non-Medical
Demographic Change Form

 

HIPAA Forms
Waiver of Medical Coverage FormIncludes Notice of Special Enrollment Rights and Consequences of Declining Coverage
HIPAA Authorization for Release of Personal Health Information (PHI)

 

Domestic Partnership Forms
Affidavit of Domestic Partnership
Declaration of Termination of Domestic Partnership

 

COBRA Forms
COBRA Notice to Employer of a Qualifying Event

 

Carrier Forms

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Life and AD&D Forms

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Basic & Voluntary Life Forms
Life Claim Packet
Beneficiary Designation Form (Minor Beneficiaries’ Payout Options)
Accelerated Benefit Claim Form for Employees
Accelerated Benefit Claim Form for Spouses / Dependents
Waiver of Premium Form
VTL Booklet (enrollment form and medical history statement attached)
Group Life Portability Application | Portability Rates are on page 4 of the VTL Certificate or page 5 of the  Life Certificate

 

Group Life Conversion Materials

Portability & Conversion Overview

Evidence of Insurability Form

Evidence of Insurability Online Submission

 

Voluntary Accidental Death & Dismemberment (VAD&D) Forms
VAD&D Claim Packet
VAD&D Booklet (enrollment form and medical history statement attached)

 

Disability Plan Forms

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Long Term Disability Forms
LTD Claim Packet
LTD Conversion Form
Buy-Up LTD Booklet (enrollment form and medical history statement attached)

Buy-Up LTD Enrollment Form

 

Voluntary Short Term Disability Form
VSTD Claim Packet
VSTD Booklet (enrollment form and medical history statement attached)

 

Consumer Driven Health Plan Forms

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Flexible Spending Arrangement
FSA/DCAP Enrollment Form
FSA Claim Form
DCAP Automatic Dependent Care Claim Request
Direct Deposit Form

 

Health Savings Account Forms
2017 HSA Enrollment Form
HSA Withdrawal Request
HSA Questions and Answers