Retiree Forms
Retiree Benefit Forms
Retiree Benefits Change Form (PDF 35 KB)- Medicare Part D Opt Out Form (PDF 9 KB)
- Division of Benefits Order (PDF 13 KB)
Claim forms
- Dental Claim Form (PDF 850 KB)
- Express Scripts Prescription Drug Claim Form (PDF 470 KB)
- Express Scripts Prescription Mail In Form (8 ½" X 14" paper required for proper printing please note both front & back side need to be printed) (326 KB)
- HIPAA Authorization for Release of Health Information Form (PDF 74 KB)
- Medical Claim Form (Coventry Health Care) (359 KB)
- Medical Claim Form (Great-West Healthcare) (PDF 1.03 MB)
- VSP Out-of-Network Reimbursement Form (112 KB)
Beneficiary Designation Forms
- Designation of Beneficiaries for AD&D Insurance (PDF 59 KB)
- Designation of Beneficiaries for Basic Group Life Insurance (PDF 15 KB)
- Designation of Beneficiaries for Retirement Benefits (PDF 37 KB)
- Designation of Beneficiaries for Deferred Vested Benefits (PDF 38 KB)
Retiree Payroll Forms
- Change of Address Form (PDF 27 KB)
- Direct Deposit Form (PDF 17 KB)
- Federal Withholding Certificates (PDF 275 KB)
- Illinois Withholding Certificate (PDF 73 KB)
- Missouri Withholding Certificate (PDF 98 KB)
- Statement of Tax Responsibility (PDF 8 KB)
Reviewed 2011-12-30.
