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Form Description Last Revised Format
     

2017-2018 Forms

   
     
2017-18 Employer Data Worksheet 11/2016 PDF
2017-18 Enrollment Form 11/2016 PDF
2017-18 Language Assistance Form 11/2016 PDF
2017-18 Group Adjustment Form 11/2016 Word
2017-18 Group Data Change Form 4/2017 PDF
2017-18 Personal Data Change Form 4/2017 PDF
2017 -18 Materials Order Form 3/2017 PDF
     

2016-2017 Forms

   
2016 -17 Employer Data Sheet 2/2016 PDF
2016 -17 Employer Data Sheet Addendum Page 2 2/2016 PDF
2016 -17 Employer Data Sheet Addendum Page 3 2/2016 PDF
2016 -17 Employer Data Sheet Addendum Page 4 2/2016 PDF
2016 -17 Enrollment Form 2/2016 PDF
2016-17 Group Adjustment Form 2/2016 Word
2016-17 Group Data Change Form 2/2016 Word
2016-17 Personal Data Change Form 2/2016 Word
     

General Forms

   
Adoption Agreement 2/2013 PDF
Adult Incapacitated Dependent Certification Form 9/2017 PDF
Appeal Form for Active Employees and Retirees Not Eligible for Medicare 7/2011 PDF
Appeal Form for Active Employees and Retirees Eligible for Medicare 9/2011 PDF
BES Reports Posted to Group Folder in HuRMan Repository 5/2013 PDF
Chip Model Notice 2/2017 PDF
COBRA/Extended Coverage Election Notice 1/2017 Word
Delta Dental Order Form 2/2016 PDF
Direct Bill - New Group Election 5/2015 Word
Direct Bill - Newly Eligible Participant 5/2015 Word
Direct Bill - Automatic Bank Draft Authorization 5/2015 Word
Extended Coverage General Notice 8/2011 Word
Group Application 2/2013 PDF
HIPAA Certificate   PDF
HIPAA Privacy Notice 9/2013 PDF
HIPAA Privacy Notice 9/2013 Word
Home Delivery Pharmacy Form   PDF
Materials Order Form for 2016-2017 Plan Year 3/2017 PDF
Medicaid and Children’s Health Insurance Form   PDF
Memo of Understanding 8/2011 PDF
Prescription Drug Exception Form 8/2015 PDF
SSN Waiver Form 2/2012 PDF
USERRA Notice   PDF
Women’s Health and Cancer Rights  Form   PDF