Member Forms

Click the form links below to review or download copies.

NOTE: You may be redirected to the member portal to access some resources.

H&W

Claim Form

Dependent Coverage Election

HRA Claim Form

HIPAA Authorization Form

Loss of Time Application

Loss of Time Tax Form

Opt Out Form - Medicare

Opt Out Form - Dependent

Participant Enrollment Form

Subrogation Agreement

Spousal Insurance Requirement Form (Part 1)

Working Spouse Employer Verification Form (Part 2)

Continuity of Care Form

Retiree Return to Work

Tax Withholding

DC to DB

Beneficiary Form