Insurance Forms
Downloading and Saving a Fillable PDF Form
Fillable PDF forms may be completed and saved using Adobe Acrobat Reader (this software must be loaded on your computer). To accomplish this, you must first save the empty form on your own computer:
--Position your cursor on the form link and click with your right mouse button (do not activate the link and open the form)
--From the menu that pops up, select the Save link as… or similar option in your browser
--You should then be prompted to choose a location to save the file
--Select the location on your own computer or network and click on the Save button
--Once saved, navigate to the file
- Enrollment Change Application — Active Members and COBRA —Plan Year 2024
- Enrollment Change Application — Active Members and COBRA —Plan Year 2023
- Certification of Eligibility for Dependents Placed with Head of Contract by Valid Placement Order
- Dependent Eligibility Certification for Dependent with Expired Placement Order
- Insurance Cancel Request Application —Plan Year 2024
- Insurance Cancel Request Application —Plan Year 2023
- Dependent Eligibility Verification Documents
- Dental Only Application for Current Members (Retirees and COBRA only) —Plan Year 2024
- Dental Only Application for Current Members (Retirees and COBRA only) — Plan Year 2023
- HSA Transfer Request Form Instructions
- Basic Term Life/AD&D Insurance Enrollment/Change Application —Plan Year 2024
- Basic Term Life/AD&D Insurance Enrollment/Change Application —Plan Year 2023
- Voluntary Accidental Death and Dismemberment Enrollment —Plan Year 2024
- Voluntary Accidental Death and Dismemberment Enrollment —Plan Year 2023
- Voluntary Term Life Enrollment Form
- Voluntary Term Life Evidence of Insurability Form
- Voluntary Term Life Beneficiary Designation Form
- Voluntary Term Life Service Request
- Voluntary Term Life Fax Cover Page
- Dismemberment and Loss of Sight Claimant Statement
- Application to Continue Insurance at Retirement —Plan Year 2024
- Application to Continue Insurance at Retirement —Plan Year 2023
- Application for The Tennessee Plan
- Retiree Insurance Change Application —Plan Year 2024
- Retiree Insurance Change Application —Plan Year 2023
- Insurance Cancel Request Application —Plan Year 2024
- Insurance Cancel Request Application —Plan Year 2023
- Dental Insurance Application —Plan Year 2024
- Dental Insurance Application —Plan Year 2023
- Dependent Eligibility Verification Documents
- Medical, Dependent Care and Limited Purpose —Plan Year 2024
- Medical, Dependent Care and Limited Purpose —Plan Year 2023
- Transportation and Parking —Plan Year 2024
- Transportation and Parking —Plan Year 2023
- Family Status Change Application