Form Title	File
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
Evidence of Insurability	G455-37
Group Enrollment Form	G457-239
Group Enrollment Form - Major Medical	G457-239 MM
Group Enrollment Form (Spanish Language)	G457-212
Verification of Dependent Eligibility	G457-58.pdf
Verification of Dependent Eligibility (Incapacitated Dependent)	V314-27.pdf
Supplemental Enrollment Forms	G354-4 or G354-5
Medical/Dental Claim Forms	G577-422/423
Investigative Consumer Reports Notification	G354-6.doc
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	V321-18.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
Dependent Student Certification	V314-15.pdf
PHCS Provider Referral Form	G594-4.pdf
Bank Funding Form Wire Information	BankForm.doc
Caremark Claim Form	Claim Form
Wellpoint RX Claim Form	Claim Form
HIPAA Privacy Forms:
Plan Sponsor Certification to the Group Health Plan
- Fully Insured	2002-25C FI
- Minimum Premium/ASO	2002-25C MP/ASO
List of Authorized Representatives	2002-26C
Change to List of Authorized Representatives	2002-26C Change
Appointment of Personal Representative	2003-24B
Notice of Privacy Practices
- Fully Insured/Minimum Premium	2002-17C FI/MP
- ASO	2002-17C ASO
Privacy Amendment
- Fully Insured/Minimum Premium	2002-24C FI/MP
- ASO	2002-24C ASO
Business Associate Agreement	2002-9C BA
Information Packets
- Fully Insured	FI 04-03
- Minimum Premium	MP 04-03
- ASO	ASO 04-03
Group Medicare Part D Forms:
- Group Medicare Part D	Group Medicare Part D
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