Forms & documents for plan administrators

All the forms and documents you need to manage your plan and take care of your plan members.

Plan administration

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Group Administrator Portal Application

pdf • 93 KB
Complete this form for access to the secure Group Administrator Portal (GAP)

Employee forms

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Individual Application for Group Benefits

pdf • 151 KB
New employees should complete this form to enroll in your Group Benefits plan.
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Individual Application for Group Benefits (H&D Only)

pdf • 140 KB
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Electronic Funds Transfer (EFT) Authorization

pdf • 198 KB
Your employees can use this form to sign up for direct deposit of their claim reimbursements.
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Employee Change Form

pdf • 249 KB
Employees should complete this form to notify us of any changes to their information.
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Beneficiary Designation Form

pdf • 125 KB
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Standard Health Claim Form

pdf • 133 KB
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Cost Plus Claim Form

pdf • 143 KB
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Prescription Drug Special Authorization Form

pdf • 203 KB
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Chronic Weight Management Special Authorization Form

pdf • 253 KB
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Travel Insurance Claim Form

pdf • 3 MB
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Group Death Claim Form

pdf • 112 KB

Application for Disability benefits

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Employer Guide: Assisting an Employee

pdf • 150 KB
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Employer’s Statement: Application for Benefits

pdf • 156 KB
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Employer: Job Description

pdf • 460 KB
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Employee Guide: Submitting a Disability Claim

pdf • 148 KB
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Employee’s Statement: Application for Benefits

pdf • 195 KB
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Employee: Education & Work History

pdf • 104 KB
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Initial Disability Insurance Medical Statement

pdf • 583 KB
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EFT Authorization for Member

pdf • 198 KB

Critical Illness claim forms

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Group Critical Condition Claim Form

pdf • 272 KB