Forms

Health Insurance:

• Employee Health Insurance Form - Enrollment/Change
• Employee Health Insurance Waiver Form - New Hires (must be completed if not electing Archdiocese coverage)
• OptumRX Mail Order Form
• UHC Medical Claim Form
• Disabled Dependent Child Certification Form

Flexible Spending Account (FSA):

• Flexible Spending Plan Election Form - Enrollment/Change
• FSA Direct Deposit Form
• Medical Reimbursement Claim Form
• Dependent Care Reimbursement Claim Form

Basic Life and Supplemental Life Insurance:

• Beneficiary Designation Form - Used for both basic and supplemental life coverage.
• Supplemental Life Insurance Form - Enrollment/Change/Cancel
• Evidence of Insurability (EOI) - To apply for additional coverage.
• Life Conversion & Portability Form
• Life/AD&D Insurance Claim Form  

Long Term Disability (LTD):

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

Employee Wellness Program:

• Employee Wellness Form - Submit for a physician's wellness check for the Wellness Plan year effective 5/1/2022 through 4/30/2023.