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.

• Application for Coverage for Other Dependent Children (Rev. 09/10/10)
• Application for Medicare Supplement With Part D (Rev. 10/03/11)
• Application for Life Premium Waiver (Rev. 04/09/09)
• Application for Retiree/Vested/Non-Vest/Defer Insurance (Rev. 02/22/11)
• Authorization to Disclose HealthChoice Information (Rev. 01/14/08)
• Beneficiary Designation Form (Rev. 08/25/11)
• Benefit Coordinator Information Form (Rev. 01/30/07)
• Certification of Previous Healthcare Coverage (Rev. 08/30/11)
• Disabled Dependent Assessment (Rev. 03/02/11)
• General Notice of COBRA Rights (Rev. 12/16/05)
• Life Insurance Application (Rev. 08/29/11)
• Life Insurance Claim Form(Rev. 11/10/11)
• Newborn Benefit Waiver (Rev. 05/14/07)
• Reasonable Alternative Documentation *NEW*
• Revocation of Authorization to Disclose HealthChoice Information (Rev. 03/06/07)
• Supply Order Form (Rev. 01/21/11)
• Submit Supply Order Online
• Tobacco-Free Attestation  *NEW
• USERRA Life Retention Form (Rev. 08/10/10)