Group Insurance Documentation

Plan Documents

Benefit Plan Document (PDF)
Dental Plan Document (PDF)
Life and AD&D Certificate (PDF)
WW Life and AD&D Certificate (PDF)
WW LTD Certificate (PDF)

HIPAA

Privacy Notice (PDF)
PHI Release (PDF)
Failure to Enroll (PDF)
Special Enrollment Provisions (PDF)
Women's Health and Cancer Rights Act (PDF)

Claim Forms

BCBS Claim Form (PDF)
Kanawha Dental Claim Form (PDF)
Life, Accidental Death, LTD (Contact Plan Administrator to initiate claim.)
Mail Order Prescription Form (PDF)

Change Forms

Change In Employment (PDF)
Medical Change Form (PDF)
Dental Change Form (PDF)
Life and AD&D Change Form (PDF)

Links

Benefits