Forms

Add/Delete Dependents Form
Use this form when you need to either add or remove dependents from the health plan.

Health Plan Enrollment Form
This form should be used to enroll in the health plan once you become eligible for coverage.

Kaiser Enrollment/Change Form
Use this form to enroll in Kaiser or to add or delete dependents in Kaiser.

Aetna Employee Enrollment/Change Form
Use this form to enroll in Aetna or to add or delete dependents in the Aetna plan.

Delta Dental Dual Choice Enrollment Form
Use this form to enroll in a Delta Dental plan.

Authorization for Release of Protected Health Information   
You can use this form to authorize the plan and administrator to release your protected health information (phi) to the individual/organization you designate.

Verification of Full-Time Student Status
Use this form to verify that your dependent child, who has reached the age of 19, is a full-time student at an accredited educational institution.

Request for Continued Coverage for Incapacitated Child
This form is required to be completed every two years if you have a dependent child who has reached the limiting age but continues to have coverage due to a mental or physical handicap.

Medical Claim Form
Use this form to obtain reimbursement for medical claims

COBRA Election Form
This form is used to initiate continuous health coverage should you experience a COBRA qualifying event.