Benefit Coordinator Forms

Listed below are forms and waivers provided to our Benefit Coordinators.  If a form cannot be located, please call 1-405-717-8780 (local) or toll-free 1-800-752-9475.

• American Fidelity Health Savings Account Application
• Application for Coverage for Other Dependent Children (Rev. 09/27/12)
• Application for Medicare Advantage Prescription Drug (MAPD) Plan - For 2013 enrollments only.
• 2013 Application for Medicare Supplement With Part D - For 2013 enrollments only.
• Application for Life Premium Waiver (Rev. 03/21/13)
• Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 03/21/13)
• Authorization to Disclose HealthChoice Information (Rev. 03/18/13)
• Beneficiary Designation Form (Rev. 10/12/12)
• Benefit Coordinator Information Form (Rev. 01/30/07)
• Certification of Previous Healthcare Coverage (Rev. 08/30/11)
• Change of Address Form (Rev. 09/25/12)
• Disability Benefits Beneficiary Designation (Rev. 11/15/12)
• Disabled Dependent Assessment (Rev. 02/28/13)
• General Notice of COBRA Rights (Rev. 12/16/05)
• Life Insurance Application (Rev. 04/08/13)
• Life Insurance Claim Form (Rev. 11/10/11)
• Newborn Benefit Waiver (Rev. 02/27/13)
• Revocation of Authorization to Disclose HealthChoice Information (Rev. 10/24/12)
• Supply Order Form (Rev. 06/03/13)
• Submit Supply Order Online
• USERRA Life Retention Form (Rev. 08/10/10)