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Member Forms


Visit the Appeals page for detailed instructions and form.

Enrollment/Change Forms

2017-18 Midyear Change Form

2018-19 Midyear Change Form (coming soon)

Beneficiary Designation Form

Tobacco Usage Status Change Form

2017-18 New Member Enrollment Form

2018-19 New Member Enrollment Form (coming soon)

Domestic Partnership

Affidavit of Domestic Partnership

Termination of Domestic Partnership Form

Optional Insurance

Unum Medical History Statement

Terminate Long Term Care Coverage

Life Insurance Medical History Statement

Special Group - HB2557

2017-18 HB2557 Midyear Change Form

2018-19 HB2557 Enrollment Form (coming soon)

2018-19 HB2557 Midyear Change Form (coming soon)

HB2557 ACH Authorization

HB2557 Terminate All Benefits Form

Special Group - Self-Pay Early Retirees (SPERS)

2017-18 SPERS Initial Enrollment Form

2017-18 SPERS Dental Only Enrollment Form

SPERS ACH Authorization

SPERS Change of Address Form

SPERS Terminate Benefits Form

2017-18 SPER Midyear Change Form

2018-19 SPERS Open Enrollment Form (coming soon)

2018-19 SPERS Open Enrollment Form - No Optional Plans (coming soon)

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