Enrollment Forms:

Dental Benefits Plan Enrollment Application

Claim Forms:

Member Submitted Dental Claim Form

FSA Plan for UCC Ministries Medical Care Expense Claim Form

FSA Plan for UCC Ministries Dependent Care Claim Form

Medical Transportation Expense Certification Form 2018

FSA Plan for UCC Ministries Change in Status Election Form

FSA Plan for UCC Ministries Election Form and Compensation Reduction Agreement Form 2020

FSA Plan for UCC Ministries Election Not to Participate Form

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

Qualifying Dependent Care Expenses Worksheet

Qualifying Medical Care Expenses Worksheet

Certification of Domestic Partner as Dependent or Non-Dependent

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

MetLife Privacy Notice

Optional Additional Death Benefit Application

Optional Additional Death Benefit Designation of Beneficiary Form

Optional Dependent Death Benefit Application

Statement of Dependent Eligibility Beyond Limiting Age in Plan Due to Mental Retardation, 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

Health Benefits Supplementation Brochure

Small Annuities Supplementation Brochure

NGLI

Click here for documents and information related to NGLI applications

Charitable Giving

UCBMA Ministerial Assistance General Information

Personal and Financial Organizer

Enrollment Forms:

Medical Benefits (Non-Medicare) Enrollment

Medicare Supplement Plan Application

Statement of Health Form

Application for Medical Benefits for Adult Children (Under Age 26)

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

Certification of Domestic Partner as Dependent or Non-Dependent

Protected Health Information Release Form