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 (2023 Rates)
• COBRA Coverage Pre-Payment Application
• Dental Claim Form
• Domestic Partner Application
• Domestic Partner Renewal Affidavit
• Domestic Partner Termination
• Health Insurance Assistance Claim Form
• Prescription Claim Form
• “Self-Pay” Enhanced Retiree Plan Enrollment Packet (2023-24 Rates)
• “Self-Pay” Enhanced Retiree Plan Enrollment Form (2023-24 Rates)
• Specialist Co-pay Reimbursement Claim Form
• Statement of Dependence Form – Custodial
• Statement of Dependence Form – Medical
• Survivor’s Beneficiary Form
• Welldyne Prescription History Request Form