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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. 

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

Health Benefits Automatic Credit Reduction Form

Protected Health Information Release Form

Pension Forms

Enrollment applications

Annuity Plan Membership and Other Benefits Form

Online Employee Retirement Contribution Agreement Form "TSA" 
For current Members

Employee Retirement Contribution Agreement Form "TSA"
For new Members

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

Health Benefits Automatic Credit Reduction 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)

Termination of Benefits/Employment

Termination of Benefits/Employment

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 Designation

Brewster Employee Retirement Contribution Agreement

Brewster Fund Reallocation Form

Brewster Hardship Withdrawal Request

Brewster In-Service Withdrawal Request

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 Cambio de Compensación para Múltiples Empleados (Ryder – Compensation change mulitple employees.)

RYDER - Formulario de Cambio de Compensación (Ryder – Compensation Change)

RYDER Formulario de Designacion de Beneficiarios

RYDER Plan de Anualidad Formulario de Inscripción

RYDER Reconocimiento del Beneficiario

RYDER Reconocimiento de Miembros

RYDER Healthcare Integrated Service - Formulario de Cambio de Compensación (Compensation Change)

RYDER Healthcare Integrated Service - Formulario de Cambio de Compensación para Múltiples Empleados (Compensation change mulitple employees)



St. Paul's Homes Forms

St. Paul's Allocation of Future Contributions 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 New Annuity Enrollment Form