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Required Forms listed by Situation

 

Single Member Enrolling

Enrollment Form Instructions

Enrollment Form

Birth Certificate or Driver’s License

Married Member with No Children

Enrollment Form Instructions

Enrollment Form

2021 Coordination of Benefits Cover Letter

2021 Coordination of Benefits Spouse Employer Form

Birth Certificate or Driver’s License for Member

Birth Certificate or Driver’s License for Spouse

Marriage Certificate

Married Member with Children and/or Stepchildren

Enrollment Form Instructions

Enrollment Form

2021 Coordination of Benefits Cover Letter

2021 Coordination of Benefits Spouse Employer Form

Birth Certificate or Driver’s License for Member

Birth Certificate or Driver’s License for Spouse

Marriage Certificate

Birth Certificate on all children showing names of both parents

If child is between the ages of 19-26:

2018 Dependent Age 19 - 26 Letter

2018 Dependent Age 19 - 26 Form

Stepchildren will also need:

Natural Father Information/Natural Mother Information

Copy of Spouse’s court documents regarding the stepchildren in its entirety

  • Divorce Decree
  • Family Court Orders

Copy of most recent Federal Income Tax Return (Only need page 1 of Federal 1040) showing dependents reside with you

Written verification from school showing stepchildren reside with you

In writing please verify the:

  • Date of birth of natural parent
  • If natural parent is married
  • If the natural parent is unemployed (This can be done on the Natural Parent Employer Form, or as part of a written statement)
  • With whom the children reside

Single Member with Children

Enrollment Form

Enrollment Form Instructions

Natural Father Information/Natural Mother Information

Birth Certificate or Driver’s License for Member

Birth Certificate on all children showing names of both parents

If child is between the ages of 19-26:

2018 Dependent Age 19 - 26 Letter

2018 Dependent Age 19 - 26 Form

Any relevant court documents regarding the children, in their entirety (If none exist, please verify this in a written statement)

  • Divorce Decrees
  • Separation Agreements
  • Family Court Orders
In writing please verify:
  • Date of birth of natural parent
  • If natural parent is married
  • If the natural parent is unemployed (This can be done on the Natural Parent Employer Form, or as part of a written statement)
  • With whom the children reside

Divorce Finalized with Spouse

New Enrollment Form

Enrollment Form Instructions

Copy of the entire finalized Divorce Decree (Must include County Clerk Stamp)

  • Any referenced other legal documents such as a Separation Agreement

Municipality Enrollment

The only differences from the above documentation needed for municipalities is as follows:

Enrollment Form for Municipalities instead of generic form

Enrollment Form Instructions instead of generic form

Spouse/Dependent Opt Out Form if you would like to not cover them on your insurance

 

General Health Forms

Eligibility Rules and COB Summary - Eligibility Rules and Coordination of Benefits Summary.

2021 Coordination of Benefits Cover Letter - Cover Letter for Coordination of Benefits Form.

2021 Coordination of Benefits Spouse Form - Form to be submitted for verification of spouse's benefits.

2018 Dependent Age 19 - 26 Cover Letter - Cover Letter for Dependent to Age 26 Enrollment Form.

2018 Dependent Age 19 - 26 Form - Form to be submitted for verification of dependent enrollment.

Change of Address- Form to notify the Fund office if you change your mailing address.

Enrollment Form Instructions - Instructions for enrolling for benefits.

Enrollment Form - Form for enrolling for benefits.

Enrollment Form for Municipalities Instructions - Instructions rnrolling Municipal Employees Only.

Enrollment Form for Municipalities - Form for enrolling for benefits. This is for Municipal Employees Only.

Spouse/Dependent Opt Out Form for Municipalities - Opt Out for Municipal Employees Only.

HIPAA Privacy Notice - Notice regarding the Health Insurance Portability and Accountability Act 0f 1996.

HIPAA Authorization Form - Form to release personal information to a third party.

Natural Father Information - Form for Natural Father Employer Coverage.

Natural Mother Information - Form for Natural Mother Employer Coverage.

Rx Reimbursement - COB Claim Form - Form for Prescription COB Claim Reimbursement.

Mail Order Rx Fax Back Form from Provider - Form for Prescription Fax Back from Provider.

Home Delivery Rx Order Form - Form for Mail Order Home Delivery Prescriptions.

 



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