forms

Benefits Updates and Alerts

Contact the BSC at 866-481-4922
Monday-Thursday 8:00-6:00 ET / Friday 8:00-5:00 ET

Quicklinks

Medical

Biometric Physician Waiver/Affidavit Form

Physician Health Coaching Engagement Waiver Form

Cigna Claim Form

Cigna Appeal Request

Cigna Authorization for Disclosure of Private Health Information

Cigna Provider Nomination Form

Healthy Life Center

Medical History

PCP and Preferred Pharmacy

Request for Representative

HSA

Fidelity Transfer of Assets QRG

Fidelity transfer assets to fidelity

Pharmacy

Express Scripts Reimbursement Claim Form

Express Scripts Mail Order Form

Basic / Voluntary Term Life

Forms will be available soon

Short-Term Disability

Employee Statement

Employer Statement

Attending Physician's Statement

Authorization to Obtain Information

New York State Short-Term Disability Claim Form

Hawaii Short-Term Disability Claim Form

Dental

Dental Claim Form

Dentist Nomination Form

Education Programs

TUITION REIMBURSEMENT

Application Packet
Tuition Reimbursement Process Checklist/Instructions
Tuition Reimbursement Application Form
Tuition Reimbursement Contract
Recommendation for Tuition Reimbursement
Tuition Reimbursement Policy Overview

Reimbursement Packet
Tuition Reimbursement Process Checklist/Instructions
Tuition Reimbursement External Request Form Quick Reference Guide
Tuition Reimbursement Expense Reporting in Concur Quick Reference Guide
Tuition Reimbursement Policy Overview

401(K) Retirement

All forms must be requested by calling Fidelity at 1-800-835-5087 or logging into www.401k.com and requesting it online.

Critical Illness Insurance

Critical Illness Claim Form

Critical Illness Claim Process

Critical Illness Health Screening Benefit Claim Form

For questions regarding a claim prior to 4/1/13, contact Unum customer service at 1-800-635-5597

Vision

Out-of-network Claim Form

Accident Insurance

Accident Claim Process
Accident Claim Form

Dependent Eligibility

Qualifying Life Event-Change in Coverage Affidavit

Spousal Healthcare Coverage Eligibility Affidavit

Sample Dependent Audit Packet

Common Law Marriage Affidavit

Temporary Certification of Tax-Dependency

Flex Spending Accounts

FSA Claim Form (Tax Saver)

Long Term Care

Benefit Change Form

Portability Form

Long-Term Disability

Authorization for release of information form

Physician’s Return to Work Release

Employee Assistance Program (EAP)

Provider Nomination Form