Insurance Carrier Forms

Life Insurance

Mutual of Omaha

• Basic Group Life Enrollment form (English)
• Basic Group Life Enrollment form (Spanish)
• Voluntary Life Enrollment form (English)
• Voluntary Life Enrollment form (Spanish)

Group Long Term Disability

Mutual of Omaha

• Mutual of Omaha Enrollment LTD Enrollment form
• Mutual of Omaha Employee Termination Form (Group/Vol life & LTD)

Group Dental

Cigna

• Add/Change/Delete form

Group Vision

Ameritas

• Add/change/delete (English)
• Add/change/delete (Spanish)

United

• Add/change/delete (English)
• Add/change/delete (Spanish)
• Out of Network Claim form

Group Medical Insurance

Aetna

• NY add/change/delete form (English)
• NY add/change/delete form (Spanish)
• CT add/change/delete form & Health Statement (English)

Oxford

• NY Enrollment form (English)
• NY Enrollment form (Spanish)
• Add/term/delete change form (English)
• Add/term/delete change form (Spanish)

Health Reimbursement Account (HRA)

Clarity

• Enrollment form (English)
• Enrollment form (Spanish)
• Change/Delete form