Forms

 

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​ Medical and Dental Access medical claim form from via Blue Cross Blue Shield of Illinois' site Access dental claim form via Delta Dental of Kansas' site Prescription Drug Caremark Prescription Claim Reimbursement Form is used for reimbursement when you pay the full cost of a prescription. Caremark Prescription Patient Profile/Mail Order Form is used to initiate the mail order program through Caremark.

Vision

• VSP Non Provider Claim Form is used if you see a non Vision Service Plan provider and need to submit a paper claim.
  
  

Private Health Authorization Form

• Authorization for the Release of Protected Health Information is used to access private health information.
  
  

Retirement

• TD AMERITRADE Plan Participant and Plan Trustee Account Form – Options Application
• Need to make or update your beneficiary designations? You can do so online with the plan record keeper, John Hancock Retirement Services at myplan.johnhancock.com.
  
  

Life Insurance and Accidental Death & Dismemberment

Visit www.lifebenefits.com to enroll and to elect your beneficiaries.

Group Universal Life (GUL) Service Request Form

This form is used to decrease or cancel GUL coverage or to elect, change or cancel GUL cash accumulation contributions. Go to www.lifebenefits.com to make changes to your GUL coverage.
 

Conversion Form

This form is used if you plan to be the owner of your child’s life insurance policy if you leave the company. Go to www.lifebenefits.com to apply for a conversion of this policy.
    

Life Insurance Conversion Form.

This form is used to continue life insurance if you retire or leave the company. Go to www.lifebenefits.com to apply for a conversion of this policy.