Western Area School Health Benefit Plan Western Area School Health Benefit Plan

 

 

 

Forms

Basic Life
Group Insurance Change Request Form - IL
Beneficiary Change Form

Billing
Payment Transmittal Form

Claims
Prescription Drug Claim Form

Enrollments/Terminations
Red Enrollment Form
Red Enrollment Form with basic dependent life

White Enrollment Form
White Enrollment Form with basic dependent life

Red Change Waiver Form
White Change Waiver Form

Flexible Spending Accounts
Flexible Spending Accounts Enrollment Form
Flexible Spending Accounts Claim Form

Voluntary Life
Benefit Summary (12 pays)
Benefit Summary (24 pays)
Evidence of Insurability Form
Portability Request Form
Life Conversion Request Form (basic life insurance)
Life Conversion Request Form (voluntary life insurance)

Health Savings Accounts
HSA Enrollment Form
HSA Transmittal Form

Notices

HIPAA Privacy Notice

Women's Health & Cancer Rights Act of 1998 (WHCRA)

Illinois Insurance Exchange Notice

 

 

Site Designed by Infobahn Outfitters, Inc.
Copyright ©