These forms are in either a .doc or a .pdf file format. To read and print the .pdf you may need to download the latest version of Adobe® Acrobat® Reader (free) from the Adobe site.
All forms must be printed, completed and signed before submission to the Payroll & Benefits Department. Electronic submission of forms is not permitted at this time.
Medical Insurance Claim Form
- Medical/Dental Claim Form – EBMS
- Medical/Dental Appeal Form– EBMS
Enrollment/Change Forms
- Cafeteria Election Form
- Enrollment Form – The Standard (Life, STD, & LTD)
- Group Life Evidence of Insurability Form – The Standard
- Vision Insurance Enrollment Form – United Healthcare
- Retiree Medical Change Form
Medcom Flexible Spending Accounts
- Forms Library – Pick the one you need!
- MedCom Claim Form & Direct Deposit Authorization
- Recurring Transaction Form
- Dependent Card Request Form
Group Life & Disability Claims
- Waiver of Premium – The Standard
- Group Life Claim Form – The Standard
- Life Conversion Packet or Port Application – The Standard
- STD_Claim_Packet – The Standard
- LTD Claim Form – The Standard
Service/Claims: Other Plans
- Life Insurance Change Form (Shenandoah)
- Trmk_Beneficiary_P357-21 or Direct Bill Request
- Trustmark Life Claim or File a Claim | Trustmark (trustmarkbenefits.com)
- Unum Life Claim
- Unum Life Online E-Sign Service Requests
- Unum Life Service Form pages 1-2 are instructions only
- Unum Life Application
- AFLAC Forms Library
- AFLAC Waiver of Premium when disabled
- AFLAC Direct Payment Authorization
- AFLAC Life Claim Form
- Aflac Life Claim Physician Statement (claim within 2 years of issue)
- AFLAC Life Service Form – Changes
- UHC Vision Out of Network Claim
- Standard Critical Illness Claim Form
- Standard Wellness Screening Benefit Form
- Standard Hospital Indemnity Claim Form
