General Forms

2019 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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All Lines Enrollment Form


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 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  (Medical History Statement)

Evidence of Insurability Online Submission 

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

Disability Plan Forms

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

Buy-Up LTD Enrollment Form

Voluntary Short Term Disability Form
VSTD Claim Packet
VSTD Booklet (enrollment form attached)

Consumer Driven Health Plan Forms

WCIF SIMON Registration and Claim Filing Options


Flexible Spending Arrangement

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

Health Savings Account Forms
2018 HSA Enrollment Form
HSA Withdrawal Request
HSA Questions and Answers

Health Reimbursement Account Forms

HRA Enrollment Form
HRA Claim Form
HRA Questions and Answers