Enrollment and Claims Forms

Technicians Insurance

Effective Aug. 1, 2020, civilian employees under Title 5 are eligible for this program. All references to Technician includes Title 32 Technicians and Title 5 civilian employees.

Enrollment

Open Enrollment - excluding NY, OH, OR, Puerto Rico, SC, SD, TX

Open  Enrollment - OH, SC, SD, TX

Open Enrollment - OR

Open Enrollment - Puerto Rico

Open Enrollment - NY

Standard Enrollment - excluding NY, OH, OR, Puerto Rico, SC, SD, TX

Standard Enrollment - OH, SC, SD, TX

Standard Enrollment - OR

Standard Enrollment - Puerto Rico

Standard Enrollment - NY

Claims

Claims Instructions

Claims Form Library

Additional Resources

Quick Reference Guide

Supply Requisition Form

Brochure - excluding NY

Brochure - NY

Request for Change Form #NG76

Accidental Death and Dismemberment

Claims

Claims Procedure

Accidental Death Claim Forms

Death Claim for Association Plans

Accidental Death - AR, IN, KY, LA, ND and RI

Accidental Death - CA, FL, MN and NY

Accidental Death - AK, IL, KS, NV and NC

Accidental Death - All other states

Accidental Dismemberment Claim Forms

Accidental Dismemberment Claim for Association-Adminstrator

Accidental Dismemberment Claim for Association Plans-Member

Authorization for Release of Health-Related Information

Attending Physicians Statement of Dismemberment

Additional Resources

AD&D Certificate

Term Life Insurance

Enrollment

Standard Enrollment

Standard Enrollment - OH, SC, SD, TX

Additional Resources

Brochure - MemberLife plan

Preferred Vision Care

Enrollment

Enrollment Form