Insurance Coordinator Documents

• American Fidelity Health Savings Account Application
• Application for Coverage for Other Dependent Children (Rev 09/27/2012)
• Application for Medicare Advantage Prescription Drug (MAPD) Plan
• 2013 Application for Medicare Supplement With Part D
• Application for Life Premium Waiver- For use by Entities with the EGID Disability Plan (Rev. 03/21/2013)
• Application for Life Premium Waiver- For use by Entities without the EGID Disability Plan (Rev. 03/21/2013)
• Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 03/21/2013)
• Authorization to Disclose HealthChoice Information (Rev. 03/18/2013)
• Beneficiary Designation Form (Rev. 10/12/2012)
• Certification of Previous Healthcare Coverage (Rev. 08/30/2011)
• Change of Address Form (Rev. 09/25/2012)
• COBRA Packet (Rev. 03/27/2012)
• Common-Law Spouse Form (Rev. 04/30/2013)
• Dependent Attachment Form (Rev. 08/18/2011)
• Disabled Dependent Assessment (Rev. 02/28/2013)
• Exclusion for Spouse Coverage (Rev. 04/08/2013)
• HIPAA Complaint Form – Privacy (Rev. 10/24/2012)
• HIPAA Complaint Form – Non-Privacy (Rev. 10/24/2012)
• Insurance Change Form with Guidelines 2013 (Rev. 10/11/2012)
• Insurance Coordinator Information Form (Rev. 03/19/2013)
• Insurance Enrollment Form with Guidelines 2013 (Rev. 09/24/2012)
• Insurance Termination Form (Rev. 10/12/2012)
• Life Insurance Application (Rev. 04/08/2013)
• Life Insurance Claim Form (Rev. 11/10/2011)
• Newborn Benefit Waiver (Rev. 02/27/2013)
• Request for Insurance Premium Refund Fill-in version (Rev. 04/02/13)
• Request for Insurance Premium Refund Print version (Rev. 11/16/2009)
• Revocation of Authorization to Disclose HealthChoice Information (Rev. 10/24/2012)
• Supply Order Form (Rev. 01/21/2011)
• Submit Supply Order Online  
• USERRA Life Retention Form (Rev. 08/10/2010)