Retiree Forms

Retiree Benefit Forms

• 2013 Retiree Annual Enrollment Change Form
• Retiree Benefits Change Form
• Medicare Part D Opt Out Form
• Division of Benefits Order

Claim forms

• Dental Claim Form
• Express Scripts Prescription Drug Claim Form
• Express Scripts Prescription Mail In Form (8 ½" X 14" paper required for proper printing ­ please note both front & back side need to be printed)
• HIPAA Authorization for Release of Health Information Form
• Medical Claim Form (Coventry Health Care)
• VSP Out-of-Network Reimbursement Form

Beneficiary Designation Forms

• Designation of Beneficiaries for AD&D Insurance
• Designation of Beneficiaries for Basic Group Life Insurance 
• Designation of Beneficiaries for Retirement Benefits
• Designation of Guaranteed Period Beneficiaries for Deferred Vested Benefits 
• Employee Contribution Refund Designation

Retiree Payroll Forms

• Change of Address Form
• Direct Deposit Form
• Federal Withholding Certificates
• Illinois Withholding Certificate
• Missouri Withholding Certificate
• Statement of Tax Responsibility

Reviewed 2013-05-17.