Dental and Medical Forms

• EZ Claim Form for Incentive PPO and Purdue 500
• Anthem Claim Form (Prescriptions)
• Anthem Mail Order Form (Prescriptions)
• Change in Family Status Form (medical)
  This effects core benefits only and does not effect voluntary benefits such as dental.
• Change in Family Status Form (dental)
  Coverage will start on the first of the month following the effective date of the change.
• Medco Mail Order Form (United Healthcare Prescriptions)
• Payroll Deduction Authorization Form

Flexible Spending Account (FSA) Forms

• Dependent Care FSA Claim Form (PDF)
• Health Care FSA Claim Form (PDF)
• FSA Direct Deposit Authorization
• Auto Reimbursement Waiver/Election Form

Retirement Forms

• How to Enroll in Tax-Deferred Annuities
• Salary Reduction Agreement Form – 403(b) Plan and 457(b) Plan
• Request for Estimate of Benefits
• Application for Waiver of TIAA/CREF Three-Year Waiting Period
• Voluntary Early Partial Retirement Form

Other Benefit Forms

• MN Life Beneficiary Designation and Change Request Form
• Prudential Short Form Health Statement
• Disabled Child Physician’s Form
• VSP Out-of-Network Claim Form