Forms

NOTE: All forms on this page are in PDF format

• Cobra Enrollment Form
• Declaration of Adult Dependent Form
• Delta Dental Claim Form
• Dependent Premium Waiver Form
• EyeMed Claim Form
• MedImpact Prescription Drug Claim Form
• MedVantx Mail Order Form
• New Employee Physicial Exam Form
• Out of State Authorization Form
• Physician's Statement for Dependent Child Form-Allegiance
• Physician's Statement for Dependent Child Form-Blue Cross
• Physician's Statement for Dependent Child Form-New West
• Standard Evidence of Insurability Form
• Standard Portability Form
• Standard Travel Benefit Brochure (regular)
• Standard Travel Benefit Brochure (Expatriate-over 90days)
• Standard Travel Benefit (Expatriate-over 90 days) Form
• Standard Travel Benefit (Expatriate-over 90 days)Certificate
• Unum Election to Continue Coverage Form

Flexible Spending Account Forms:

• Flex Annual Enrollment form (2013_14)
  

Allegiance Plan Management Flex Forms (2013_14):

• Adoption Assistance form
• Adoption Assistance Program
• Day Care Reimbursement contract
• Debit Card form
• Direct Deposit form
• Flex Claim Dependent Care form
• Flex Claim Medical form

Peak1 Flex Forms(2012_13):

• Adoption Assistance Claim form
• Adoption Assistance Information
• Claims Rollover form
• Dependent Reimbursement form
• Direct Deposit form
• Medical Reimbursement form
• Medical Necessity form
• Mid Year Change form
• Peak1 Debit Card form

2012-13 Forms and Workbooks

Active Enrollment Form Choices Annual Benefits Enrollment Workbook Retiree Enrollment Form Choices Retiree Annual Benefits Enrollment Workbook MAP Enrollment Form (must include the Retiree Enrollment form also) Mid-Year Enrollment Form Summary Plan Description (SPD) effective July 1, 2012