Benefit Coordinator Forms

Listed below are forms and waivers provided to our Benefit Coordinators.  If a form cannot be located, please call us at 1-405-717-8780(local) or Toll Free at 1-800-752-9475.

• Application for Coverage for Other Dependent Children (Rev. 09/10/10) NEW!  Replaces the Declaration of Dependency effective 01/01/2011.
• Application for HealthChoice Employer PDP Medicare supplement With Part D (Rev. 09/08/09)
• Application for Life Premium Waiver (Rev. 04/09/09)
• Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 05/05/10)
• Authorization to Disclose Health Information (Rev. 01/14/08)
• Beneficiary Designation Form (Rev. 08/06/09)
• Benefit Coordinator Information Form (Rev. 01/30/07)
• Declaration of Dependency (Rev. 03/02/09) This form expires on 12/31/2010.  Please use the Application for Coverage for Other Dependent Children
  for effective dates 01/01/2011 or after.
• Disabled Dependent Assessment (Rev. 03/05/10)
• General Notice of COBRA Rights (Rev. 12/16/05)
• Life Insurance Application (Rev. 07/21/09)
• Life Insurance Claim Form(Rev. 04/07/10)
• Newborn Benefit Waiver (Rev. 05/14/07)
• Revocation of Authorization to Disclose Health Information (Rev. 03/06/07)
• Supply Order Form (Rev. 04/23/10)
• USERRA Life Retention Form (Rev. 08/10/10)