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Forms & Applications
- Accidental Dismemberment or Loss of Sight Claim Form (Rev. 4/11/2013)
- American Fidelity Health Savings Account Application
- Application for Life Premium Waiver- For use by Entities with the EGID Disability Plan (pdf)
- Application for Medicare Advantage Prescription Drug (MA-PD) Plan (Rev. 8/21/2018)
- Application for Medicare Supplement With Prescription Drug Plan (Rev. 8/21/2018) – For 2019 Enrollments
- Application for Medicare Supplement With Prescription Drug Plan (Rev. 3/13/2018) – For 2018 Enrollments
- Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 9/13/2017)
- Authorization to Disclose HealthChoice Information (Rev. 10/11/2018)
- Beneficiary Designation Form (Rev. 10/24/2018)
- Certification of Previous Healthcare Coverage (Rev. 8/8/2016)
- Change of Address Form (Rev. 06/29/2018)
- Disability Benefits Beneficiary Designation (Rev. 8/8/2018)
- Electronic Fund Transfer Authorization (Rev. 3/25/2013)
- Electronic Funds Transfer Form for Alternate Payees (Rev. 11/16/2015)
- Life Insurance Claim Form
- Medicare Complaint Form - Health or Prescription Coverage
- Medicare Part D Prescription Claim Form
- Member Audit Form (Rev. 6/30/2015)
- Prescription Reimbursement Claim Form
- Revocation of Authorization to Disclose HealthChoice Information (Rev. 1/26/2016)
- TRICARE Supplement