Insurance Coordinator Documents

• 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- For use by Entities with the OSEEGIB Disability Plan (Rev. 04/09/09)
• Application for Life Premium Waiver- For use by Entities without the OSEEGIB Disability Plan (Rev. 03/10/09)
• Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 07/09/10)
• Authorization to Disclose Health Information (Rev. 01/14/08)
• Beneficiary Designation Form (Rev. 08/06/09)
• Common-Law Spouse Form (Rev. 08/30/06)
• 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.
• Dependent Attachment Form (Rev. 07/27/06)
• Disabled Dependent Assessment (Rev. 03/05/10)
• Exclusion for Spouse Coverage (Rev. 07/21/06)
• Insurance Change Form with Guidelines and Privacy Notice 2011 (Rev. 11/23/10)
• Insurance Coordinator Information Form (Rev. 04/08/08)
• Insurance Enrollment Form (Rev. 03/03/09)
• Insurance Termination Form (Rev. 03/25/08)
• Life Insurance Application (Rev. 07/21/09)
• Life Insurance Claim Form (Rev. 04/07/10)
• Newborn Benefit Waiver (Rev. 05/04/07)
• Request for Insurance Premium Refund (Rev. 11/16/09)
• Revocation of Authorization to Disclose Health Information (Rev. 03/06/07)
• Supply Order Form (Rev. 09/22/08)
• USERRA Life Retention Form (Rev. 08/10/10)