Forms

RETIREE

• Retiree Change of Address Form

MEDICAL

• UnitedHealthcare Domestic Medical Claim Form (For non-EPO service claims - PPO)

• UnitedHealthcare International Medical Claim Form

• Universal Enrollment Form

PRESCRIPTION DRUGS (Rx)

• MEDCO - Retail Claim Form

• MEDCO - Mail Order Form

DENTAL

• Delta Dental Claim Form

VISION

• No forms are needed at this time. Claims should be sent directly to VSP from your provider, or you may call VSP to request a customized claim form: 1-800-877-7195.

EAP

• No forms are needed at this time. Complimentary services (visits) should be pre-authorized by dialing EAP at (866) 248-4105 or online at www.liveandworkwell.com.

GROUP TERM LIFE INSURANCE

• Hartford Insurance Death Claim form

• Hartford Beneficiary Designation Form

• Hartford Life Portability Application Form

• Hartford Notice of Conversion Form

SUPPLEMENTAL TERM LIFE INSURANCE

• Supplemental Life and AD&D Application-Personal Health Form*

• Hartford Beneficiary Designation Form*

• Hartford Insurance Death Claim form

  *NOTE: these forms are mandatory

FLEXIBLE SPENDING ACCOUNTS (FSA) - HEALTH CARE (HCA) and DEPENDENT CARE (DCA)

• Flexible Spending Account Enrollment Form 1011: for both Health and Dependent Care Accounts (PY 10/11)

• FSA-UHC Claim Form
  Important Deadline for FSA claims submission:
  • PY 09/10 - September 30, 2010*
    
  • PY 10/11 - September 30, 2011*
    

    *Terminated employees must submit FSA claim form within 90 days from the last day of coverage.

• FSA UHC Direct Deposit Request Form

WORKER'S COMP

To be completed by the injured worker (The worker may be assisted by health services):
• State of California Employer's Report Form (Form 5020)

• Workers' Comp Report of Injury Form

• DWC-1

Last Updated: Tuesday, May 8, 2012 at 3:24:15 PM
©2012 Foothill-De Anza Community College District