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Dental Forms

We recently updated our forms and applications. Please select the link for the applicable benefits in which you want to enroll and complete the application. If you are enrolling in Life Insurance and Disability Income benefits you must also complete the Life Insurance and Disability Income (LIDI) Metlife Enrollment Change form.

Enrollment Forms:

Dental Benefits Plan Enrollment Application Only - For enrollment period of October 1-31 of every Plan Year

Annuity Plan Membership and Other Benefits Form - For enrollment in the dental plan or other benefit plans outside of open enrollment

Dental Benefits Plan Summary:

2022 UCC Dental Plan Schedule

Claim Forms:

Member Submitted Dental Claim Form

Flexible Spending Account Forms

Election Forms

FSA Plan for UCC Ministries Election Form and Compensation Reduction Agreement Form 2021

FSA Plan for UCC Ministries Change in Status Election Form

FSA Plan for UCC Ministries Revocation of Benefit Election and Compensation Reduction Agreement Form

FSA Plan for UCC Ministries Election Not to Participate Form

 

Health FSA

FSA Plan for UCC Ministries Medical Care Expense Claim Form

Qualifying Medical Care Expenses Worksheet

 

Dependent Care FSA

FSA Plan for UCC Ministries Dependent Care Claim Form

Qualifying Dependent Care Expenses Worksheet

Medical Forms

We recently updated our forms and applications. Please select the link for the applicable benefits in which you want to enroll and complete the application. If you are enrolling in Life Insurance and Disability Income benefits you must also complete the Life Insurance and Disability Income (LIDI) Metlife Enrollment Change form.

Enrollment Forms:

Medical (Non-Medicare) and Dental Benefits Enrollment

Medicare Advantage Plan and Dental Benefits Enrollment Form

Continuation of Coverage Form

Statement of Health Form

Small Employer Exemption (SEE) Form

Medical Claim Form:

To obtain a member submitted claim form or international claim form, please visit the Highmark website at www.highmarkbcbs.com or contact customer service at 866.763.9471 for assistance.

Pharmacy Claim Form:

To obtain a pharmacy reimbursement form, please login to your account at www.express-scripts.com or contact customer service at 800.939.3781 for assistance.

Other Health Plan Related Forms:

Domestic Partnership Statement of Financial Interdependence Form

Protected Health Information Release Form

Pension Forms

Enrollment applications

Annuity Plan Membership and Other Benefits Form

Employee Retirement Contribution Agreement Form
Formerly the "TSA Salary Reduction Agreement"

Retirement Savings Account (RSA) Application

Rollover Contribution Account (RCA) Agreement Form

Beneficiary Designation forms

Annuity Plan UCC Beneficiary Designation Form

Fund Reallocation forms

Annuity Plan Fund Transfer

Allocation of Future Contributions and Fund Reallocation Form

Banking forms

Direct Deposit Agreement Form

Wire Transfer Consent Form

Tax Resources

Special Tax Notice

Withholding Certificate for Pension or Annuity Payments


Fund Withdrawals

Account Balance Distribution

Retirement Savings Account (RSA) and Rollover Contribution Account (RCA) Withdrawal Application

Transfer - Rollover Funds

Request for Direct Rollover of Funds to the Pension Boards

Update Salary Information

Employee Change Form

Employer Compensation Change Form (formerly Salary Report Form)

Death Benefit Forms

Beneficiary Acknowledgement Form

Claimants Affidavit

Death Benefits for Estates

Post-Retirement Pension Death Benefits Form

Pre-Retirement Death Benefits for Spouse Form

Pre-Retirement Death Benefits for Non-Spouse Form



Brewster Forms

Brewster Allocation of Future Contributions and Fund Reallocation Form

Brewster Annuity Plan Membership

Brewster Beneficiary Acknowledgement Form

Brewster Beneficiary Designation

Brewster Employee Retirement Contribution Agreement

Brewster Fund Reallocation Form

Brewster Hardship Withdrawal Request

Brewster In-Service Withdrawal Request

Brewster Member Acknowledgement Form

Brewster Rollover Agreement (RCA) Form

Brewster Rollover Contribution Account (RCA) Withdrawal Form



CHAMPS Homes Forms

CHAMPS Homes Allocation of Future and Fund Allocations Form

CHAMPS Homes Annuity Plan Membership Application

CHAMPS Homes Annuity Plan Member Acknowledgement Form

CHAMPS Homes Annuity Plan Beneficiary Acknowledgement Form

CHAMPS Homes Beneficiary Designation

CHAMPS Homes Employee Retirement Contribution Form



Mt. San Antonio Gardens Forms

MSAG New Annuity Plan Membership Application

MSAG Annuity Plan Member Acknowledgement Form

MSAG Annuity Plan Beneficiary Acknowledgement Form

MSAG Allocation of Future Contributions and Fund Reallocation Form



Ryder Memorial Forms

RYDER Acuerdo de Aportaciones Personales del Empleado

RYDER Formulario de Asignación de Contribuciones Futuras y Reasignación de Fondos

RYDER Formulario de Designacion de Beneficiarios

RYDER Plan de Anualidad Formulario de Inscripción

RYDER Reconocimiento del Beneficiario

RYDER Reconocimiento de Miembros

RYDER Healthcare Integrated Services Compensation Change

RYDER Healthcare Integrated Services Compensation Change - Multiple Employees



St. Paul's Homes Forms

St. Paul's Allocation of Future Contributions Form

St. Paul's Beneficiary Acknowledgement Form

St. Paul's Beneficiary Designation Form

St. Paul's Employee Retirement Contribution Agreement (ERCA) Form

St. Paul's Fund Transfer Form

St. Paul's Member Acknowledgement Form

St. Paul's New Annuity Enrollment Form