Forms

Enrollment, Change, Termination and Claim Forms

Please see your benefits administrator at your parish/school/office/agency regarding any benefit changes first for eligibility. If you are eligible for an enrollment, change, or termination, all completed forms need to be submitted to your benefits administrator.

Health Insurance Form for Medical and Dental coverage

• Health Insurance Form to enroll_change-cancel coverage
• Billing Update Form
• Billing Update Fillable Form
• UHC Medical Claim Form 124 Kb
• UHC Member Request Appeal Form 2010 86.96 Kb
• United Healthcare Prescription Claim form 87.38 Kb
• UnitedHealthcare-Medco Mailorder Form
• Delta Dental Claim form 544.08 Kb

Flexible Spending Account (FSA) Forms

• FSA Election Form 2012 - 2013
• FSA Election Form to Enroll_Change_Cancel Coverage
• FSA Medical Claim Form
• FSA Reimbursement Dependent Care Claim form
• How to File FSA Claims Online
• Direct Deposit Form For FSA Claim Reimbursements

Retirement Forms

• Retirement Participant Information Change Form
• Beneficiary Designation Form for Diversified 403(b) Plan
• Salary Reduction Agreement Form For Diversified Plan 2012

Long Term Disability Forms

• Unum LTD Disability Claim Form

Voluntary Life Insurance Forms

• Hartford Enrollment/Change/Cancel Form
• Hartford Personal Health Application
• Hartford Life Insurance Death Claim Form

Administration

•  2011 - 2012 Benefits Administration Manual
• Certificate of Creditable Coverage Form

Family Medical Leave Act (FMLA)

• FMLA Facts and Information
• Notice of Eligibility and Rights and Responsibilities WH-381
• Employee Healthcare Provider Certificate WH-380-E
• Family Member Healthcare Provider Certification WH-380-F
• Employer Designation Notice WH382