Employee Benefits

Applications and Forms

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Health

• Employee Coverage Declination Form
• Employee HSA/HRA Addendum
• Employer HRA Addendum
• Employer Group Health Application/Change Form (1-15 Employees)
• Employer Group Health Application/Change Form (16+ Employees)
• Employee Enrollment/Change Application (1-15 Employees)
• Employee Enrollment/Change Application (16+ Employees)
• Employer HSA Addendum
• Domestic Partner Affidavit
• Group Administrator Guide

Dental

• Domestic Partner Declaration
• Employee Enrollment Form
• Employer Dental Application/Change Form
• Request for Participation

Life

• USAble Life Evidence of Insurability
• Enrollment Application and Change Form Addendum (Life Insurance)
• Life Product Selection Form
• Salary Update Form

Claim Forms

• Dental
• Life
• Medical
• Prescription Drugs

Other

• North Carolina Medical Society Membership Application
• North Carolina Medical Society Membership Verification Form
• Quote Request Form