Forms
Form Description Last Posted Format
     

2019-2020 Forms

   
     
2019-20 Enrollment Form 3/2019 PDF
2019-20 Group Data Change Form 3/2019 PDF
2019-20 Materials Order Form 3/2019 PDF
2019-20 Personal Data Change Form 3/2019 PDF

2018-2019 Forms

   
     
2018-19 Employer Data Worksheet 1/2018 PDF
2018-19 Enrollment Form 1/2018 PDF
2018-19 Group Adjustment Form 1/2018 PDF
2018-19 Group Data Change Form 1/2018 PDF
2018-19 Material Orders Form 1/2018 PDF
2018-19 Personal Data Change Form 1/2018 PDF
     

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 12/2017 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