Forms

Please make a selection from the menu below:

1. Generic Forms and Notices
2. Dental
3. Medical
4. Vision
5. Group Term Life
6. Short Term Disability
7. Long Term Disability

Employee Forms and Notices

1. Continuation of Coverage for Disabled Dependents Form PDF
2. Language Assistance Program Notice (for CA groups) PDF
3. HIPAA Notice English | Spanish
4. Termination Form (for terming an employee's coverage) Word | PDF
5. COBRA Form PDF

DENTAL

1. Idaho Universal Employee Enrollment Form PDF
2. Ohio Uniform Employee Application PDF
3. Utah Universal Employee Enrollment Form PDF
4. Dental Group Roster (to enroll employees) Word | PDF | Excel
5. CA English Dental Only Enrollment Form Word | PDF
   
6. CA Spanish Dental Only Enrollment Form Word | PDF
7. CA English Dental/Vision Enrollment Form Word | PDF
8. CA Spanish Dental/Vision Enrollment Form Word | PDF
9. English Dental Only Enrollment Form Online | Word | PDF
   
10. Spanish Dental Only Enrollment Form Word | PDF
11. English Dental/Vision Enrollment Form Online | Word | PDF
12. Spanish Dental/Vision Enrollment Form Word | PDF
    
13. Affidavit of Domestic Partnership Form Word | PDF
14. Dental Claim Form PDF

MEDICAL

Health Solutions II - Co-pay PPO

1. Health Solutions II Enrollment Form (National) Online | Word | PDF
2. Health Solutions II Enrollment Form (Texas) Online | Word | PDF
3. Health Solutions II Enrollment Form (Arizona) PDF
4. Idaho Universal Employee Enrollment Form PDF
5. Illinois Standard Health Application (for employees) PDF
6. Ohio Uniform Employee Application PDF
7. Utah Universal Employee Enrollment Form PDF
8. Group Medical Claim Form PDF
9. CVS Caremark Mail Order Form PDF
10. View a Current Drug List PDF
    
11. CVS Caremark Prescription Drug Claim Form PDF
    

Health Solutions I - HDHP

1. HDHP Employee Enrollment Form Online | Word | PDF
2. HDHP Employee Enrollment Form (Texas) Online | Word | PDF
3. HDHP Employee Enrollment Form (Arizona) PDF
4. Idaho Universal Employee Enrollment Form PDF
5. Illinois Standard Health Application (for employees) PDF
6. Ohio Uniform Employee Application PDF
7. Utah Universal Employee Enrollment Form PDF
8. Group Medical Claim Form PDF
9. CVS Caremark Mail Order Form PDF
10. View a Current Drug List PDF
    
11. HDHP Prescription Drug Claim Form PDF

VISION

1. English Enrollment Form Online | Word | PDF
2. Spanish Enrollment Form Word | PDF
3. Ohio Uniform Employee Application PDF
4. Utah Universal Employee Enrollment Form PDF
5. Vision Group Roster (to enroll employees) Word | PDF | Excel
6. Vision Indemnity Claim Form PDF
7. Vision PPO Out-of-Network Claim Form PDF
   

GROUP TERM LIFE

1. Ohio Uniform Employee Application PDF
2. Gold, Silver and Bronze Life Enrollment Form Word | PDF
3. Essential Life Enrollment Form Word | PDF
4. Passport Life Enrollment Form Word | PDF
   
5. Flex Life Enrollment Form Word | PDF
6. Group Term Life Roster (to enroll employees) Word | PDF | Excel
7. Change of Beneficiary Word | PDF
8. Employee Death Benefits Claim Form PDF
9. Dependents Death Benefits Claim Form PDF
10. AD&D Claim Form PDF
11. Accelerated Benefits Claim Form PDF
12. Waiver of Premium Claim Form PDF

SHORT TERM DISABILITY

1. Illinois Standard Health Application (for employees) PDF
2. Short Term Disability Enrollment Form Word | PDF
3. Short Term Disability Enrollment Form (Kentucky) Word | PDF
4. Group Roster (for groups with no late entrants) Word | PDF | Excel
5. STD Waiver of Coverage PDF
6. STD Claim Form Word | PDF

LONG TERM DISABILITY

1. Long Term Disability Enrollment Form Word | PDF
2. Ohio Uniform Employee Application PDF