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.

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

Election Forms

FSA Plan for UCC Ministries Election Form and Compensation Reduction Agreement Form 2022

FSA Change in Status 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

Domestic Partnership Statement of Financial Interdependence Form  

Life Insurance (LIDI) Designation of Beneficiary Form

Life Insurance and Disability Income (LIDI) Benefit Plan Enrollment Application

Life Insurance and Disability Income (LIDI) MetLife Enrollment Change Form

Optional & Additional Life Insurance Forms

Optional Additional Death Benefit Designation of Beneficiary Form

Statement of Dependent Eligibility Beyond Limiting Age in Plan Due to Mental or Physical Handicap

Statement of Health Form

Grants & Supplementation

Application for Ministerial Assistance

Higher Education Scholarships for Children of Disabled or Deceased Ministers

Herring Stark Memorial Funds Application

Ministerial Assistance Eligibility Criteria

NGLI

Click here for documents and information related to NGLI applications

Charitable Giving

UCBMA Ministerial Assistance General Information

Personal and Financial Organizer

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. 

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

Non-Medicare 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