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Medical Forms

Enrollment Forms:

Medical (Non-Medicare) and Dental Benefits Enrollment

Medicare Advantage Plan and Dental Benefits Enrollment Form

Medical and Dental Benefits Annual Change Form

Continuation of Coverage Form

Statement of Health Form

Application for Medical Benefits for Adult Children (Under Age 26)

Medical Claim Form:

To obtain a member submitted claim form or international claim form, please visit the Highmark website at www.highmarkbcbs.com or contact customer service at 866.763.9471 for assistance.

Pharmacy Claim Form:

To obtain a pharmacy reimbursement form, please login to your account at www.express-scripts.com or contact customer service at 800.939.3781 for assistance.

Other Health Plan Related Forms:

Domestic Partnership Statement of Financial Interdependence Form

Certification of Domestic Partner as Dependent or Non-Dependent

Protected Health Information Release Form

Pension Forms

Enrollment applications

Annuity Plan Membership Application

Employee Retirement Contribution Agreement Form
Formerly the "TSA Salary Reduction Agreement"

Retirement Savings Account (RSA) Application

Rollover Contribution Account (RCA) Agreement Form

Beneficiary Designation forms

Annuity Plan UCC Beneficiary Designation Form

Designation of Beneficiary/120 Payments Form

Retirement Saving Account Beneficiary Designation Form 

Fund Reallocation forms

Allocation of Future Contributions and Fund Reallocation Form

Annuity Plan UCC Fund Reallocation Form

Banking forms

Direct Deposit Agreement Form

Wire Transfer Consent Form

Tax Resources

Special Tax Notice

Withholding Certificate for Pension or Annuity Payments

Fund Withdrawals

Retirement Savings Account Withdrawal Application

Rollover Contribution Account Withdrawal Application

Transfer - Rollover Funds

Request for Direct Rollover of Funds to the Pension Boards

Update Salary Information

Employer Change Form (formerly Salary Report Form)

Supplementation Forms

Pension Data Sheet

Death Benefit Forms

Beneficiary Acknowledgement Form

Claimants Affidavit

Death Benefits for Estates

Post-Retirement Pension Death Benefits Form

Pre-Retirement Death Benefits for Spouse Under Age 50 Form

Pre-Retirement Death Benefits for Spouse Over Age 50 Form



Brewster Forms

Brewster Allocation of Future Contributions

Brewster Annuity Plan Membership

Brewster Beneficiary Designation

Brewster Employee Retirement Contribution Agreement

Brewster Hardship Withdrawal Request

Brewster In-Service Withdrawal Request



CHAMPS Homes Forms

CHAMPS Homes Annuity Plan Membership Application

CHAMPS Homes Allocation of Future Contributions



Mt. San Antonio Gardens Forms

MSAG New Annuity Plan Membership Application

MSAG Allocation of Future Contributions and Fund Reallocation Form



St. Paul's Homes Forms

St. Paul's Allocation of Future Contributions Form

St. Paul's New Annuity Enrollment Form