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Medical Forms

Enrollment Forms:

Medical (Non-Medicare) and Dental Benefits Enrollment

Medicare Advantage Plan and Dental Benefits Enrollment Form

Medical and Dental Benefits Annual Change Form

Continuation of Coverage Form

Statement of Health 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 Benefit Plans Enrollment

Annuity Plan Member Acknowledgement Form

Annuity Plan Beneficiary Acknowledgement 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

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

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

Transfer - Rollover Funds

Annuity Plan Fund Transfer Form

Request for Direct Rollover of Funds to the Pension Boards

Update Salary Information

Employee Change Form (formerly Salary Report Form)

Employer Compensation Change 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



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