2010 Employee

• Amendment to Original Application (Nonsmoker Certification) (50.5 KB)
• Employee Enrollment/Change (389.8 KB)
• Employee Enrollment/Change for Medical Only Groups (449.9 KB)
• Life Insurance Change Form (140.7 KB)
• Life Insurance Enrollment Form (101.3 KB)
• Life Insurance Evidence of Insurability (80.5 KB)
• Long Term Disability Enrollment/Change Form (45 KB)
• Long Term Disability Evidence of Insurability (42.1 KB)
• Section 125 Waiver Form (128.4 KB)

2010 Retiree

• Medicare Advantage Disenrollment (Form D) (271.8 KB)
• Medicare Advantage Enrollment (Form C) (368.5 KB)
• Medicare Supplement Enrollment (Form B) (302.2 KB)
• Retiree Coverage Election Form (Form A) (585.8 KB)

2010 Dependent Certification

• Adult Dependent Enrollment/Change (366.6 KB)
• Declaration of Marriage or Qualified Domestic Partnership (use for dependent verification only, not enrollment) (447.9 KB)
• Dependents with Disabilities (326.6 KB)
• Determining Dependent Tax Status (includes Declaration of Tax Status Form) (292.8 KB)
• Extended (Legal) Dependents (385.6 KB)
• Student Certification/Change (234.3 KB)

2010 Continuation of Coverage

• COBRA Continuation of Coverage Election (469.7 KB)
• Group Life Portability Application (86.2 KB)
• Leave Without Pay (450.8 KB)
• Uniform Medical Conversion Plan Enrollment Form (241.2 KB)

2010 Reduced-Premium COBRA

• COBRA Continuation Coverage Election Form for Premium Reduction (71.5 KB)
• For Information on Reduced-Premium COBRA, See the Publications Page
• Participant's Notice of Other Health Coverage (for reduced-premium COBRA members only) (54.2 KB)
• Request for Treatment as an Assistance Eligible Individual (69 KB)

2010 Miscellaneous

• Authorization for Release of Information (53.1 KB)
• Change in Beneficiary (Employees: Submit to your payroll office) (62.3 KB)
• Electronic Debit Service Agreement (132.2 KB)
• Notice of Appeal (267.7 KB)
• Request for Review (244.5 KB)
• Request to Cancel Dependent Coverage (54.9 KB)