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 Auto Payment

HRA Claim Form

HIPPA 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

Working Spouse Employer Verification Form

Retiree Return to Work

Tax Withholding

DC to DB