Insurance Coordinators
- Premiums and Premium Charts
- Member Handbooks
- Summary of Benefits and Coverage (SBC)
- 2021 Benefit Options Guide
- Life Insurance Application Brochure
- Filing for Life Benefits – Brochure
- 2021 BlueLincs HMO ZIP Code Service Area
- 2021 CommunityCare HMO ZIP Code Service Area
- 2021 GlobalHealth HMO ZIP Code Service Area
- TRICARE Supplement
VENDOR CONTACTS AND MATERIAL REQUESTS
American Rescue Plan Act COBRA Materials
- COBRA Packet New – For employees who have experienced a COBRA qualifying event that is a reduction in hours or an involuntary termination of employment and have not been mailed a packet previously.
- COBRA Packet Second Election Period – For members that were previously mailed a COBRA packet and experienced a COBRA Qualifying Event that is a reduction in hours or an involuntary termination of employment. – must be mailed by May 31, 2021.
- FAQs about COBRA premium assistance under the American Rescue Plan Act of 2021.
- American Fidelity Health Savings Account Application (.pdf)
- Application for Coverage for Other Dependent Children (.pdf)
- Application for Medicare Advantage Prescription Drug (MAPD) Plan (.pdf)
- Application for Medicare Supplement With Prescription Drug Plan (.pdf)
- Application for Retiree/Vested/Non-Vest/Defer Insurance (.pdf)
- Authorization to Disclose HealthChoice Information (.pdf)
- Beneficiary Designation Form (.pdf)
- Certification of Previous Healthcare Coverage (.pdf)
- Change of Address (.pdf)
- COBRA Packet (.pdf)
- Common-Law Spouse Certification (.pdf)
- Dependent Attachment Form (.pdf)
- Disabled Dependent Assessment (.pdf)
- Exclusion for Spouse Coverage (.pdf)
- HIPAA Complaint Form – Privacy
- HIPAA Complaint Form – Non-Privacy (.pdf)
- Insurance Change Form With Guidelines 2021 (.pdf)
- Insurance Change Form With Guidelines 2020 (.pdf)
- Insurance Coordinator Information and Notice (.pdf)
- Insurance Enrollment Form With Guidelines 2021 (.pdf)
- Insurance Enrollment Form With Guidelines 2020 (.pdf)
- Insurance Termination Form (.pdf)
- Life Insurance Application – Mid-year Changes (.pdf)
- Life Insurance Application – New Hire (.pdf)
- Life Insurance Claim Form Packet (.pdf)
- Newborn Limited Benefit Waiver (.pdf)
- Request for Insurance Premium Refund (.pdf)
- Request for Insurance Premium Refund Fill-In (.pdf)
- Revocation of Authorization to Disclose HealthChoice Information (.pdf)
- Supply Order Form (.pdf)
- Submit Supply Order Online
- TRICARE Supplement Plan (.pdf)
- USERRA Life Retention Form (.pdf)
Last Modified on
Jun 23, 2021
