Forms

Consent to Receive Electronic Notices
Prudential Enrollment Form – NY Employees | Outside of NY Employees
Affidavit of Domestic Partnership
Prudential Beneficiary Designation Form
Prudential Evidence of Insurability Form

Medical Forms:
Anthem Medical Claim Form
Prescription Reimbursement Claim Form

Dental Forms:
Anthem Dental Claim Form

Vision Forms:
Anthem Vision Claim Form

FSA Forms:
Flexible Spending Account (FSA) Claim Form
Flexible Spending Account (FSA) Claim Form with Transit

Life & AD&D Forms:
Beneficiary Statement – For All Other Employer Contracts
UNUM Accident Claim Form
UNUM Whole Life Claim Form

Disability Forms:
Employer Statement  
Short Term Disability and Long Term Disability Claimant Statement  
Attending Physician’s Statement  
Medical Authorization  
EFT Authorization  

CERTIFICATION OF HEALTH CARE PROVIDER FOR California Family Rights Act (CFRA) or Family and Medical Leave Act (FMLA)

CERTIFICATION OF HEALTH CARE PROVIDER – CT

CERTIFICATION OF HEALTH CARE PROVIDER – NJ

CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE’S SERIOUS HEALTH CONDITION (Family and Medical Leave Act)

CERTIFICATION FOR MILITARY FAMILY LEAVE FOR QUALIFYING EXIGENCY (Family and Medical Leave Act)

CERTIFICATION OF HEALTH CARE PROVIDER FOR FAMILY MEMBER’S SERIOUS HEALTH CONDITION (Family and Medical Leave Act)

CERTIFICATION SERIOUS INJURY OR ILLNESS OF A CURRENT SERVICEMEMBER FOR MILITARY CAREGIVER LEAVE (Family and Medical Leave Act)

CERTIFICATION FOR SERIOUS INJURY OR ILLNESS OF A VETERAN FOR MILITARY CAREGIVER LEAVE (Family and Medical Leave Act)

CERTIFICATION OF HEALTH CARE PROVIDER – OR (Family and Medical Leave Act (FMLA) and/or the Oregon Family Leave Act (OFLA)

AUTHORIZATION TO RELEASE AND OBTAIN INFORMATION

AUTHORIZATION TO RETURN TO WORK

Consent to Receive Electronic Notices
Prudential Beneficiary Designation Form
Prudential Evidence of Insurability Form

Affidavit for Annual Physical Exam