Insurance Forms
Benefit Forms
- BlueCross BlueShield Medical Care Claim Form
- BlueCross BlueShield International Medical Claim Form
- Dependent Enrollment/Change Form HR 101 – add or drop dependents from an employee’s/retiree’s coverage. (updated 7/16)
- TAMUS Dependent Child’s Statement of Disability HR 182 (updated 7/13)
- Medicare Coordination Acknowledgment Form HR 106 This form should be signed by retiring employees. (updated 11/22)
- Retiree Benefit Enrollment Form HR 107 – Used by employees to change from active to retiree status or by retirees when making a change in benefit coverage. (updated 4/16)
- Survivor Health/Dental/Vision Continuation Form HR 112 (updated 9/25)
- Grandchild Certification Form HR 120 (updated 9/19)
- Tobacco User Change Form HR 108 (updated 9/12)
Express Scripts
- Express Scripts Prescription Drug Program Member Reimbursement (updated 5/14)
- Express Scripts Home Delivery Order Form (updated 1/19)
- Express Scripts Medicare Part D Claim Form (updated 1/19)
Delta Dental
New York Life Long-Term Disability forms