Forms

Employee Benefit Forms

Health Insurance Forms with UnitedHealthcare, Delta Dental, and DeltaVision

• Employee Health Insurance Form - Enrollment/Change/Cancel
• Employee Health Insurance Waiver Form - New Hires
• OptumRX Mail Order Form
• Medical Claim Form

Employee Wellness Program

• The Employee Wellness Form to submit for a physician's wellness check for the Wellness Plan year effective 5/1/2021 through 4/30/2022.

Life Insurance with Hartford Life

• Beneficiary Form for Hartford Life
• Voluntary Term Life Insurance Form - Enrollment/Change/Cancel
• Personal Health Application - To apply for Additional Coverage
• Life Insurance Claim Form  

Flexible Spending Account with Tristar

• Flexible Spending Election Form - Enrollment/Change/Cancel
• Medical Reimbursement Claim Form
• Dependent Care Reimbursement Claim Form

Long Term Disability with Unum

• LTD Claim Form - To apply for long term disability benefits