Coverage Change Form

Submit to Benefit Services to add or drop a dependent and/or change coverage within 31 days of qualifying event

Claim Form - Delta Dental

Submit a dental claim to Delta Dental for reimbursement if your dentist does not

Claim Form - Humana

Submit a health claim to Humana for reimbursement if your provider does not

Claim Form - Humana Prescription

Submit a prescription claim to Humana for reimbursement

Prescription Mail Order -Humana RightSource

Order a 3-month supply of your prescription via mail order

Provider Nomination- Humana

If your provider is not in the Humana network and you would like Humana to contact them to join

HSA Employee Contribution Change

Submit to Benefit Services to change the amount you contribute to your HSA per pay period

HSA Beneficiary Designation

Submit to United Missouri Bank (UMB) to designate a beneficiary for your HSA

2012 HSA Eligibility Form

Complete and submit to Benefit Services upon electing the HDHP with a HSA in order for any funds to be deposited into your HSA

HSA Deposit Slip

Redeposit money mistakenly withdrawn from your account; rollover or transfer money from another HSA

Benny Debit Card Substantiation Form

Submit to Chard Snyder upon request to verify that your Benny card usage was for eligible expenses

Change of Status Request

Submit to Benefit Services within 31 days of any change (qualifying event)

Direct Deposit Authorization

Submit to Chard Snyder if you wish your reimbursements be made via direct deposit into your personal account

Employee Reimbursement Request Form

Submit to Chard Snyder with receipts to request reimbursement from your FSA

Life Insurance

Beneficiary Change Form for Life Insurance

Submit to Benefit Services when you want to change your beneficiary for group life, group accidental death, voluntary life and/or voluntary accidental death

Evidence of Insurability (Liberty Mutual)

Complete and submit to Liberty Mutual when you enroll in the voluntary life coverage for the first time during open enrollment or if you elect more than $350,000 coverage for yourself.

Voluntary Life and Group Accident Insurance Cancellation/Change

Submit to Benefit Services within 31 days of a qualifying event in order to change or cancel your voluntary coverage.

Retirement

Retirement Plan Election
for new employees

New employees who choose an ARP, must set up their ARP account with the vendor and complete, sign, date and submit this form to Benefit Services

Same-Sex Domestic Partner Benefits

Affidavit of Same Sex Domestic Partnership

Submit to Benefit Services to establish your SSDPartnership for benefits purposes

Affidavit of Termination of Domestic Partner Status

Submit to Benefit Services within 31 days of termination of partnership

Taxability of Domestic Partner Benefits

Submit to Benefit Services to demonstrate that your SSDP qualfies as a tax dependent

Tuition Fee Waiver

Tuition Fee Waiver Dependent Affidavit