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)
• Employer HSA Addendum
• Domestic Partner Affidavit

> New and Renewing Groups: Coverage Effective Dates On or After August 1, 2007

• Employee Enrollment/Change Application (1-15 Employees)
• Employee Enrollment/Change Application (16+ Employees)

> New and Renewing Groups: Coverage Effective Dates Before August 1, 2007

• Employee Enrollment/Change Application (1-15 Employees)
• Employee Enrollment/Change Application (16+ Employees)

DENTAL

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

LIFE

• USAble Life Evidence of Insurability
• Life Addendum

CLAIM FORMS

• Dental
• Life
• Medical
• Prescription Drugs

OTHER

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