Forms

Benefits Election Form – Click Here

United Healthcare Medical Enrollment / Waiver Form
United Healthcare Medical Change Form
United Healthcare Claim Form
United Healthcare Pharmacy Reimbursement Claim Form
United Healthcare Mail Order Pharmacy Reimbursement Claim Form
Guardian Dental Enrollment Form
Guardian Dental Claim Form

Guardian Enrollment Form
Guardian Vision Claim Form

Mutual of Omaha Beneficiary Designation Form
Mutual of Omaha Life and AD&D Enrollment Form
Mutual of Omaha Life Claim Form (Spanish)
Mutual of Omaha Disability Claim Form
Mutual of Omaha Disability Claim Form (Spanish)
Mutual of Omaha LTD Enrollment Form
Mutual of Omaha LTD Claim Form
Mutual of Omaha Voluntary Life Enrollment Form
Mutual of Omaha Voluntary STD Enrollment Form
Mutual of Omaha Voluntary STD Claim Form
Mutual of Omaha Voluntary STD Claim Form Filing Instructions
Mutual of Omaha Evidence of Insurability Form
Mutual of Omaha Life Conversion Form
Mutual of Omaha Life Portability Form
Mutual of Omaha Proof of Death Claim Form

FSA Enrollment Form
Flexible Spending Plan Claim Form
Direct Deposit Authorization Form
Day Care FSA Receipt for Services
Letter of Medical Necessity
401(k) Auto Enrollment Notice
401(k) Enrollment Form
401(k) Beneficiary Designation Form
401(k) Advice Questionnaire
401(k) Newport Group Opt-Out Form