Forms
Please choose a form below to download.
Statement of Claim Form / Medical Claim Form
To submit the Statement of Claim / Medical Claim Form you can download the form from this link and submit the completed claim form to the address provided at the top of the form. You must complete and sign a Statement of Claim form at least once each year.
Dental Claim Form
To submit a dental claim for processing you can download a Dental Claim Form from this link and submit completed claim form to the address provided at the top of the form.
Envision Claim Form
This claim form is to be used only when it has been necessary to purchase prescriptions because your participating pharmacy did not honor your identification card or was unable to directly submit your claim. It should also be used when it was necessary to have your prescriptions filled at a non-participating pharmacy.
Pension Direct Deposit Form
Please fill this form out to authorize Pension check direct deposit.
HRA Reimbursement Form
Please use this form to submit a Healthcare Reimbursement Account reimbursement request.
COVID-19 Tax Deferral Withdrawal Application
Please use this form to request an Emergency withdrawal from the Tax Deferral Plan. Both the application and IRS-W4 form must be completed and provided to the Administrative Office. The form requires a notary which cannot be waived.