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.

Short Term Disability Form

Please fill this form out to file a Short Term Disability report.

Pension Direct Deposit Form

Please fill this form out to authorize Pension check direct deposit.

Pension Application Form

Please fill this form out to request a Pension distribution.

HRA Reimbursement Form

Please use this form to submit a Healthcare Reimbursement Account reimbursement request.