Forms

• Authorize For Release of Information Form
• Bereavement Beneficiary Form (starting 2021)
• Beneficiary Form for Lincoln Financial
• Change of Address Form
• Check Replacement Affidavit
• COBRA Coverage Application (2022 Rates)
• COBRA Coverage Pre-Payment Application
• Dental Claim Form
• Domestic Partner Application
• Prescription Claim Form
• “Self-Pay” Enhanced Retiree Plan Enrollment Packet (2022-23 Rates)
• “Self-Pay” Enhanced Retiree Plan Enrollment Form (2022-23 Rates)
• Statement of Dependence Form – Custodial
• Statement of Dependence Form – Medical
• Survivor’s Beneficiary Form
• Welldyne Prescription History Request Form