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Benefits Forms & Links

If you cannot read any of these files after downloading them, please call Human Resources at ext. 7757 and request the appropriate form.

       
Health Insurance Blue Cross 2009 Medical Election Form Sample
    2010 Medical Election Form Sample
    Enrollment & Change Form Sample
    Dependent Certification Sample
    Provider Link  
    Medical Claim Form  
    International Claim Form 1-800-810-2583
    Authorization Delegate Form (HIPAA)  
    Prescription Claim Form  
    Magellan Mental Health Link 1-800-991-5638
 
Dental Insurance CIGNA Enrollment & Change Form Sample
    Provider link  
    PPO Claim Form  
    PPO Summary  
    PPO ID Card (generic)  
    2009 DHMO Charge Schedule  
    2010 DHMO Charge Schedule  
 
Flexible Spending Account(s) Ceridian 2009 Enrollment Form  
    2010 Enrollment Form  
    Direct Deposit  
    Benefit Card Information  
    Additional Benefit Card Enrollment Form  
    Participating Benefit Card Merchant Listings  
    Sample Health Care Expense Eligibility  
    Status Change Form  
    Medical Reimbursement Form  
    Dependent Care Reimbursement Form  
 
Vision VSP Enrollment & Change Form Sample
    Provider Link  
    VSP Plan Enhancements Summary  
    VSP Plan Enhancement for Contact Wearers  
    Out of Network Claim Form  
 
Life & AD&D SunLife Enrollment & Change Form Sample
    Evidence Of Insurability Form  
    Online Evidence of Insurability Group # 90429
    Change of Beneficiary(ies) Form  
    Life Conversion Kit  
    Life Conversion Form  
    Emergency Travel Assistance  
 
Group Supplemental Retirement Account   2009 Salary Reduction Agreement  
    2010 Salary Reduction Agreement  
       
Long-Term Disability CIGNA Tax Designation Form  
    Claim Form (Physician)  
    Claim Form (Employee)  
       
Tuition Remission   Employee - Paper form Online Form
    Dependent/Spouse - Paper form Online Form
    Statement of Dependency  
    Tax Dependency Affidavit  
       
FACHEX   What is FACHEX?  
    FACHEX Certification Form  
       
Adoption Assistance   Adoption Assistance Request  
       
Leave of Absence   Leave Request Form  
    Employee - Health Certification Form  
    Family - Health Certification Form  
    Military Exigency Certification Form  
    Covered Service Member Certification Form  
    FMLA Employee Rights & Responsibilities Notice  
       
Separation Summary   TIAA-CREF Exit Summary  
    Separation of Benefits  

 

Updated May 15, 2006