FORMS

Flexible Spending– Consolidated Admin Solutions

• Medical Claim Form
• Change Status Form
• Card Request Form

Medical / SHBP

• All enrollments/changes must be made through the
  • ADP Enrollment Portal

Dental– Delta

• Claim Form

Vision– Spectera/United Helathcare

• Statement of Dependent Eligibility

Critical Illness– Unum

• Beneficiary Designation Form
• Claim Form
• Port Request when Terminating Employment and Port Brochure for additional information

Group Life– Lincoln Financial

• Beneficiary Designation Form
• Claim Form or Dependent Claim
• Port Coverage Request Form
• Application for Portability
• Conversion Form
• Evidence of Insurability (EOI) Form
• Waiver of Life Premium (Totally Disabled)

Whole Life– Unum

• Beneficiary Change Form
• Claim Form

Short Term Disability– Lincoln Financial

• Employee Claim Form
• Employer Statement
• Attending Physician Statement
• Combined Employee, Employer, Physician Statement

Long Term Disability– Lincoln Financial

• Employee Claim
• Employer Statement
• Attending Physician Statement
• Combined Employee, Employer, Physician Statement

Cancer Guardian

• Continuation Form