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Forms
Notice of Election- Active Notice of Election (NOE) - (309KB - PDF)
- Active Notice of Election (NOE) - Permanent Part-Time Teacher - (266KB - PDF)
- Certification Regarding Tobacco Use - (28KB - PDF)
- State Health Plan (SHP)
- Health Expenses Claim Form and Instructions - 2 pages - (19KB - PDF)
- Prescription Drug Claim Form (Coordination of Benefits/Direct) and Instructions - 2 pages - (134KB - PDF)
- Request for Blue Cross and Blue Shield Card (SHP ID Card) - (29KB - PDF)
- Prescription Drug Mail Order Form and Instructions - 2 pages - (213KB - PDF)
- CIGNA HealthCare Network (HMO)
- Health Expenses Claim Form - CIGNA - (136KB - PDF)
- Prescription Drug Claim Form - CIGNA - (64KB - PDF)
- BlueChoice HealthPlan (HMO)
- Health Expenses Claim Form - BlueChoice - (40KB - PDF)
- Dental Claim Form and Instructions - (56KB - PDF)
- Life Insurance Planner Worksheet - (1.3MB - PDF)
- Statement of Health (interactive version) - (119KB - DOC)
- Statement of Health (printable version) - (42KB - PDF)
- Notice of Continuation of Coverage (Basic Life, Optional Life and Dependent Life) and Instructions - 2 pages - (26KB - PDF)
- Personal Health Application - 5 pages - (242KB - PDF)
- Group Life Insurance Portability Enrollment Form - (22KB - PDF)
- Accidental Dismemberment/Loss of Sight Claim Form (employer’s statement, employee’s statement and physician's treatment/statement) (Basic Life, Optional Life) - 2 pages - (627KB - PDF)
- Accelerated Benefit (Living Benefit Option) - 7 pages - (326KB - PDF)
- Basic Long Term Disability Certificate - (153KB - PDF)
- Supplemental Long Term Disability Certificate - (192KB - PDF)
- Medical History Statement for Late Entrants and Instructions - 3 pages
- LTD Benefits Claim Form packet - 16 pages - (130KB - PDF)
Includes:- Instructions (p.1-2);
- Employee's Statement (p.3-6);
- Authorization to Obtain Information (p. 7-8);
- Authorization to Obtain Psychotherapy Notes (p. 9-10);
- Attending Physician's Statement (p. 11-13);
- Employer's Statement (p. 13-16);
- Request for Long Term Disability Conversion Materials - (337KB - PDF)
- Long Term Care Fast Facts - (193KB - PDF)
- 2010 MoneyPlu$ Enrollment Form - 2 pages - (281KB - PDF)
- 2009 MoneyPlu$ Enrollment Form - 2 pages - (144KB - PDF)
- MoneyPlu$ Claim Form - 2 pages (interactive version) - (238KB - PDF)
- MoneyPlu$ Claim Form - 2 pages (printable version) - (185KB - PDF)
- MoneyPlu$ Refusal to Participate Statement - (21KB - PDF)
- MoneyPlu$ Worksheets - (74KB - PDF)
- MoneyPlu$ Direct Deposit Authorization Form and Terms and Conditions for Participating - 2 pages - (40KB - PDF)
- MoneyPlu$ Change in Status Form - (53KB - PDF)
- HIPAA Information
- Student Certification Form - (93KB - PDF)
- Incapacitated Child Certification Form - (60KB - PDF)
- Employment Verification Record and Instructions - 2 pages - (64KB - PDF)
- Dependent Social Security Number Form - (17KB - PDF)
- Notice of COBRA Qualifying Event - (30KB - PDF)
- Universal Name/Address Change Form - (13KB - PDF)
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