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Administration Forms

Form Title File
Evidence of Insurability G455-37
Group Enrollment Form G457-239
Group Enrollment Form - Major Medical G457-239 MM
Beneficiary Change Form (Milwaukee Public Schools) G457-235.pdf
Coordination of Benefits V319-60(TL).pdf
Affidavit, Release and Hold Harmless Agreement V321-2(TL).pdf
Verification of Dependent Eligibility (Incapacitated Dependent) V314-27.pdf
Beneficiary Designation and Change Form G457-187(TL).pdf
Request for Change Form G457-4(TL).pdf
Request for Cancellation of Insurance G457-37(TL).pdf
Employee Termination Listing G457-115(TL).pdf
Group Waiver of Premium/Extended Death Benefit V321-35.pdf
Proof of Death V321-51.pdf
Proof of Loss of Limb(s) or Sight Statements V321-27.pdf
Group Long Term Disability Claim Form V321-12.pdf
Group Short Term Disability Claim Form V321-21.pdf
Group Conversion Request G457-33.pdf
Application For Continuation of Coverage G457-88.pdf
Kansas Application for Continuation of Coverage G457-238(TL).pdf
Automatic Payment Withdrawal Authorization Form G457-218.pdf
Bank Funding Form Wire Information BankForm.doc
CVS Caremark Claim Form Claim Form
Dependent Student Certification V314-15(TL).pdf
HIPAA Privacy Forms:
Notice of Privacy Practices Privacy Notice 2016
Plan Sponsor Certification to the Group Health Plan
         - Fully Insured Yes PHI Plan Sponsor Election form
         - Fully Insured No PHI Plan Sponsor Election form
         - Cash-Flow Advantage/ASO PSA-SF
Change to List of Authorized Representatives 2002-26D
Appointment of Personal Representative 2003-24B
Privacy Amendment
         - Fully Insured/Minimum Premium 2002-24C FI/MP
         - ASO 2002-24C ASO
Business Associate Agreement
         - Trustmark as Business Associate 2009-04A BA
         - Trustmark as Covered Entity. 2009-04A CE
Information Packets
         - Fully Insured FI 04-03
         - Minimum Premium MP 04-03
         - ASO ASO 04-03
Group Medicare Part D:
         - US Department of Health and Human Services US Department of Health and Human Services
Express Informational Packets:
Express Group Administrator User Guide Express Group Admin Guide.pdf
Express Employee Guide Express Employee Guide.pdf
Express Group Administrator Guide for Enrolling an Employee in Benefits Express Admin Guide Enrolling Employee in Benefits.pdf
Express Group Administrator Guide to Your Menu Options Express Admin Understanding Your Menu.pdf
Employee Guide for Enrolling in Benefits Express Employee Guide Enrolling in Benefits.pdf
Employee Guide for Viewing and Changing Benefits Express Employee Guide Viewing and Changing Benefits.pdf
Express Sign Up Form Express Sign Up Form.doc
Express Guided Tour Express Guided Tour.pps

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