Enrollment Forms
- Apply Online!
Easily apply online for Disability and Life insurance coverage by using our DocuSign application form. Please refer to the Member Enrollment Booklet for coverage details, premium amounts and terms and exclusions. - Disability and Life Insurance Enrollment Form (Print)
Use this link if you prefer to print the enrollment form. You can then mail or fax the application to us. Please refer to the Member Enrollment Booklet for coverage details, premium amounts and terms and exclusions. - Medical History Statement (Submit Online)
Use this link to provide proof of good health when it’s required for your enrollment. You may need to complete a separate statement for your spouse/domestic partner if requested. Instructions: to begin, please use Policy Number 501000. For Division/Location, select your current district. When prompted, select coverage(s) you are applying for: Long Term Disability and/or Life. - Beneficiary Designation/Change (Print)
Use this form to specify beneficiaries for benefits related to your voluntary Life and Disability coverage. Designating beneficiaries is an optional process.
Change Forms
- Participant Change (Print)
Use this form to reinstate your coverage or update your address, name and salary information. - Beneficiary Designation/Change (Print)
Use this form to specify beneficiaries for benefits related to your voluntary Life and Disability coverage. Designating beneficiaries is an optional process. - Coverage Termination (Print)
Use this form to terminate part or all of your coverage(s).
Claim Forms
- Disability Benefits Claim Packet (Print)
Use this packet if you need all forms related to filing a disability claim (including employer's and physician's statements and authorizations). - Life Insurance Benefits Application Packet (Print)
Use this packet if you need all forms related to filing a life claim.
Continuation Forms
- Temporary Leave Continuation of Life Insurance (Print)
Use this form to continue your life insurance during a temporary leave of absence resulting from a temporary layoff, a scheduled leave of absence approved by your employer, a state mandated Family or Medical Leave Act, or a strike, lockout or other work stoppage caused by a labor dispute. - Request for Group Life Conversion Materials (Print)
Use to request application to convert group life insurance to an individual policy after insurance ends.
