Forms & Applications
- Accidental Dismemberment or Loss of Sight Claim Form (Rev. 03/25/2019)
- American Fidelity Health Savings Account Application
- Application for Life Premium Waiver- For use by Entities with the EGID Disability Plan
- Application for Medicare Advantage Prescription Drug (MAPD) Plan (Rev. 01/14/2021)
- Application for Medicare Supplement With Prescription Drug Plan (Rev. 09/28/2020)
- Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 10/24/2019)
- Authorization to Disclose HealthChoice Information (Rev. 03/15/2021)
- Beneficiary Designation Form (Rev. 01/05/2021)
- Certification of Previous Coverage (Rev. 03/15/2021)
- Change of Address Form (Rev. 01/11/2021)
- Disability Benefits Beneficiary Designation (Rev. 08/08/2018)
- Disability Reimbursement Agreement (Rev. 08/14/2020)
- Durable Power of Attorney
- Electronic Fund Transfer Authorization (Rev. 7/29/2020)
- Life Insurance Claim Form Packet
- Medicare Complaint Form - Health or Prescription Coverage
- Medicare Part D Prescription Claim Form
- Member Audit Form (Rev. 02/01/2021)
- Prescription Reimbursement Claim Form
- Revocation of Authorization to Disclose HealthChoice Information (Rev. 03/15/2021)
- TRICARE Supplement
