PDF Downloadable
INSURANCE /
BENEFIT
FORMS
HEALTH:
Coordination
of Benefits Form
To complete if you or your dependents
maintain other health insurances
Prior/Concurrent
Coverage Affidavit (for credit towards pre-existing conditions)
Authorization
to Release “PHI”-Access (allows you to choose who has access to your
claims)
Accident Form
(to use if you or your dependents sustain injuries involving vehicles/boats,
etc…)
Overage
Dependent Verification Form (use to verify eligibility of dependent
children over age 19)
PRESCRIPTION
DRUGS:
Mail Order
Pharmacy Form w/Instructions
Prime Mail Pharmacy FAX Order
Form w/Instructions
FLEXIBLE
SPENDING ACCOUNTS:
Medical
Spending/DCAP change/Enrollment Form
Day Care Reimbursement Enrollment
Form
Smart Flex Submittal of Proof Form
LIFE
INSURANCE:
Group Certificate Change Form
To use when changing or electing
beneficiaries
To use when applying for, increasing,
decreasing or terminating voluntary life coverage
REMEMBER THE 2 IMPORTANT RULES:
1. If you want your dependents to have
voluntary life insurance, you MUST
1st have coverage on yourself (The
Employee).
2. Your Dependents can only have coverage of up to 50% of what you
(The Employee) has or has
applied for.
Evidence of Insurability/Employee Application (For Voluntary Life Insurance)
To use if applying for more than the
maximum guaranteed issue amounts as follows:
100 thousand employee, 50 thousand spouse, 15
thousand child).
Application To Port
Voluntary Group Life Insurance
Allows you to apply for continuation of voluntary life coverage after
termination of employment