FORMS

		Forms for Active Employees
		Forms for Retirees/Survivors
		Forms for Adjunct Faculty

• Enrollment/Change For 2003-2004 Active Employees
  (Active File 10)
  
  
• Blue Cross - Change Form (Common Form 01)
• Blue Cross - Patient Claim Form (Common Form 02)
• Blue Cross - Prescription Drug Claim Form (Common Form 03)
• SafeGuard - Health Plans Change Form (Common Form 04)
• Kaiser Change Form (Common Form 05)

• Certification of Video Display Terminal Use (Active File 11)

Life Insurance Forms for Active Employees:

• Fortis Voluntary Life Insurance Application Form
  (Active File 12)
• Fortis Life Insurance Beneficiary Form (New Employees)
  (Active File 13)
• Fortis Life Insurance Request for Change of Beneficiary
  (Active File 14)

Domestic Partner Forms for Active Employees:

• Program Summary (Common Form 06)
• Affidavit (Common Form 07)
• Tax Form (Common Form 08)
• Premium Rates 2002-2003 (Common Form 09)
• Premium Rates 2003-2004 (Common Form 10)

Medical Insurance for Active Employees:

Blue Cross
     Blue Cross Plan (Active File 17)
     Mandatory Legislative Contract Changes (Active File 18)
Cigna
     Summary of Benefits (Active File 19)
Kaiser
     Kaiser Plan (Active File 20)
     Mandatory Legislative Contract Changes (Active File 21)

Dental Insurance for Active Employees:
     
     Dental Plan (Active File 22)

Vision Insurance for Active Employees:
     
     Vision Plan (Active File 23)

Life Insurance for Active Employees:
    
     Life Insurance Plan (Active File 24)

Employee Assistance Program (EAP) (Active File 25)
Enrollment/Eligibility Information (Active File 26)

Plans for October 1, 2003 to September 30, 2004

General Forms for Retirees/Survivors:

• Enrollment/Change For 2003-2004 Retirees
  (Retiree/Survivor File 10)
  
• Blue Cross - Change Form (Common Form 01)
• Blue Cross - Patient Claim Form (Common Form 02)
• Blue Cross - Prescription Drug Claim Form (Common Form 03)
• SafeGuard - Health Plans Change Form (Common Form 04)
• Kaiser Change Form (Common Form 05)

Domestic Partner Forms for Retirees/Survivors:

• Program Summary (Common Form 06)
• Affidavit (Common Form 07)
• Tax Form (Common Form 08)
• Premium Rates 2002-2003 (Common Form 09)
• Premium Rates 2003-2004 (Common Form 10)

Medical Insurance for Retirees/Survivors:

Blue Cross
     Blue Cross Plan (Retiree/Survivor File 11)
Cigna
     Cigna Plan (Retiree/Survivor File 12)
Kaiser
     Kaiser Plan (Retiree/Survivor File 13)

Dental Insurance for Retirees/Survivors:
     
     Blue Cross (Retiree/Survivor File 14)
     SafeGuard (Retiree/Survivor File 15)

Vision Insurance for Retirees/Survivors:
     
     Vision Plan (Retiree/Survivor File 16)
     
Employee Assistance Program (EAP) (Retiree/Survivor File 17)

Plans for October 1, 2003 to September 30, 2004

General Forms for Adjunct Faculty:

• Enrollment/Change For 2003-2004 Adjunct Faculty
  (Adjunct File 10)

• Blue Cross - Change Form (Common Form 01)
• Blue Cross - Patient Claim Form (Common Form 02)
• Blue Cross - Prescription Drug Claim Form (Common Form 03)
• SafeGuard - Health Plans Change Form (Common Form 04)
• Kaiser Change Form (Common Form 05)

• Application for Access to Medical/Dental/Vision Plans for Eligible Adjunct (Part-Time Temporary) Faculty (Adjunct File 11)

Domestic Partner Forms for Adjunct Faculty:

• Program Summary (Common Form 06)
• Affidavit (Common Form 07)
• Tax Form (Common Form 08)
• Premium Rates 2002-2003 (Common Form 09)
• Premium Rates 2003-2004 (Common Form 10)

Medical Insurance for Adjunct Faculty:

• Blue Cross Plan (Adjunct File 13)
• Cigna Plan (Adjunct File 14)
• Kaiser Plan (Adjunct File 15)

Dental Insurance for Adjunct Faculty:

• Blue Cross (Adjunct File 16)
• SafeGuard (Adjunct File 17)

Vision Insurance for Adjunct Faculty:

• Vision Plan (Adjunct File 18)