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	2008 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)
		2008 DHMO Charge Schedule

Flexible Spending Account(s)	Ceridian	Enrollment Form
		Direct Deposit
		Expense Eligibility List
		Sample Health Care Expense Eligibility
		Status Change Form
		Medical Reimbursement Form
		Dependent Care Reimbursement Form

Vision	VSP	Enrollment & Change Form	Sample
		Provider Link
		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		2008 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

FACHEX		What is FACHEX?
		FACHEX Certification Form

Adoption Assistance		Adoption Assistance Request

Leave of Absence		Leave Request Form
		Physician's Certification
		FMLA Employee Rights Notice

Separation Summary		TIAA-CREF Exit Summary
		2008 Separation of Benefits

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