Forms

Decatur County Board of Education Open Enrollment 2016

Please find below Forms that are located on the Page of each coverage described in the summary of benefits. The Forms are also located here.

Group Term Life Insurance

Group Term Life Enrollment Forms K100664057

Humana Enrollment Application
Humana Enrollment Application EOI
Humana PAL Change Form
Humana Life Contract – Policy
Humana Life Increase $10,000 Short Form

Humana Life Increase Short Form $10,000 Online   Enroll_button
Humana Enrollment Application – Online  Enroll_button
Humana Enrollment Application – EOI – Online  Enroll_button

Group Term Life Other Change & Service Forms

Humana Life Group Term Life Conversion Instructions
Humana Life Portability Coverage Form
Humana Waiver of Premium Form
Humana Death Claim Form

New Humana Portability Form   *

New Humana Portability EFT Form  *

Universal Life

Universal Life – Applications & Quotes

Symetra Universal Life Quote – Click here
Symetra Life Cover Description
Symetra Life – Premium Summary by Ages
Symetra Life Application
Symetra Life Application On Line
Symetra Life Children’s Term Life Application
Symetra Universal Life Application – Online   Enroll_button

Universal Life – Change Forms

Symetra Life – Billing Change Form Request
Symetra Life – Change of Beneficiary Form Request
Symetra Life – Life Brochure
Symetra Life – New Teachers Cover for UL Life

AD&D Enrollment Forms

AD&D Online Application  Enroll_button
AD&D PDF – Application
AD&D PDF- New Employee Cover

AD&D Portability Form

Short Term Disability Enrollment Forms

Short Term Disability – Online Application    Enroll_button
Short Term Disability Application – PDF
Summary of Benefits – STD
Claim Form – Short Term Disability

Long Term Disability Forms

Long Term Disability Application Online   Enroll_button
Long Term Disability Application with EOI Form
Long Term Disability EOI Form
Long Term Disability Policy

Long Term Disability Claim Form
Long Term Disability Waiver Form

Dental Reimbursement Forms

Dental Reimbursement Application – Online   Enroll_button
Dental Reimbursement Application – PDF
Dental Claim Form – PDF
Dental Policy Booklet – PDF

Vision Forms

Vision Application – Online  Enroll_button
Vision Brochure
Vision Application
Vision Out of Network Claim Form

Vision – Out of Network Claim Form with Account Number  Enroll_button

Avesis – Customer Service800-584-4214

Change Forms

Discontinuation & Change Form Online  Enroll_button
Discontinuation & Change Form

 

One Comment

  1. Dan1257 August 3, 2012 9:15 am

    Forms page is where you will be able to print out forms, or apply on line. Look for updates to this page soon

    George E Daniel Jr

Post a Comment

2012 Danielhealth
^ Back to Top