Forms

Please note that benefits enrollment is completed online through Paycom.

Health Net Medical Claim Form
Health Net Prescription Claim Form
Health Net Prescription Mail Order Form

Kaiser Claim Form

Direct Dental Claim Form
VSP Vision Claim Form

Mutual of Omaha Life Claim Form
How to File a Life Claim Form
Mutual of Omaha Beneficiary Designation Form
Mutual of Omaha Portability vs. Conversion
Mutual of Omaha Basic Life/AD & D and Voluntary Conversion Form

Mutual of Omaha Evidence of Insurability Online Submission
Mutual of Omaha Life Evidence of Insurability Form
Mutual of Omaha Disability Evidence of Insurability Form
Mutual of Omaha Critical Illness Evidence of Insurability Form
Mutual of Omaha Evidence of Insurability Online Submission

Mutual of Omaha LTD Claim Form
Mutual of Omaha STD Claim Form
How to File a STD Claim Form

FSA Debit Card Request and Direct Deposit Form
FSA Claim Form

Basic Life/AD & D and Voluntary Conversion Form
Basic Life/AD & D and Voluntary Portability Form
Voluntary STD/Disability Continuation Form
Voluntary Critical Illness Claim Form
Voluntary Accident Claim Form