Forms

• Authorize For Release of Information Form
• Beneficiary Form for Bereavement Benefit
• Beneficiary Form for Metlife (Active)
• Beneficiary Form for Metlife (Retired)
• Beneficiary Form for Metlife Voluntary Life
• Beneficiary Form for Survivors Benefit
• Change of Address Form
• Check Replacement Affidavit
• COBRA Coverage Application (2023 Rates)
• COBRA Coverage Pre-Payment Application
• Dental Claim Form
• Disability Claim Form – Short Term (Metlife)
• Domestic Partner Application
• Domestic Partner Renewal Affidavit
• Domestic Partner Termination
• Health Insurance Assistance Claim Form
• Hearing Aid Medical Out-of-Network Claim Form (Empire BC/BS)
• Opt-Out, Opt-Back-In 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