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Dental Forms

Enrollment Forms:

Dental Benefits Plan Enrollment Application

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

Life & Disability Forms

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

Medical Forms

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

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

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

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

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


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