Information Change

Choose a form below

Select an information form. To print the form, click on the form itself, and then select "File" and "Print" from your browser menu.

Once you have filled out the printed form, please sign it and return it to the fax number or address that you see at the top of this page.

Health Insurance Enrollment Form

Health Insurance Disenrollment Form

Request for Furlough Cost

The enrollment and disenrollment forms for Pre-Medicare Insurance, as well as the Request for Furlough Cost form, are fillable forms. Please fill out your form online, then print and sign it before mailing it to the Plan.

Forms for the Out of State Premium Reimbursement - Please print and fill out both forms linked below:

REIMBURSEMENT APPLICATION PACKET - Non-Medicare Eligible Members

REIMBURSEMENT APPLICATION PACKET - Members Over Age 65

REIMBURSEMENT AFFIDAVIT