US Insurance Forms
Optional Life Application Form
The Optional Life Application Form is used by new employees to enroll or by current employees to enroll or increase life insurance for themselves and their spouses who are already on the CSI insurance plan.
If applying more than 30 days past your date of hire, or if spouse coverage greater than $50,000 is desired, an Evidence of Insurability Form will also need to be filled out.
Optional Vision Plan Form
The Optional Vision Plan Form is used to apply for vision coverage. Optional Vision is a one-year commitment and enrollments will be accepted only for a September 1 effective date.
Cobra Instructions and Cobra Forms A & B
COBRA Instructions is for administrators and is a list of steps to take when a participant has terminated employment or has a dependent who no longer qualifies for coverage on their parents’ policy.
COBRA Form A is completed by the employer and either sent directly to CSI or given to the participant who is applying for COBRA coverage.
COBRA Form B is completed by the participant or dependent of the participant who is applying for COBRA coverage. If no coverage is needed, this form should be completed and the waiver should be signed.
Insurance Limited Benefit Application Form
The Limited Benefit Application Form is used to add a new hire, add or delete dependents for life, AD&D, LTD and Dental.
Beneficiary Change Form – UNUM
The Beneficiary Change Form is used to change the beneficiary on the active participant’s life insurance policy.
Trustmark Request for Change Form
The Request for Change Form is used when an address or name change occurs.
Trustmark Verification of Dependent Eligibility
The Verification of Dependent Eligibility is used when you have a child over the age of 19 who is a full time student and is covered for benefits on one of Trustmark’s health plans and/or dental plans.
Trustmark Wellpoint Prescription Form
Wellpoint Prescription Form is the Trustmark website to obtain prescription forms such as:
Mail Order Form
Addresses for sending in your claims
All claim forms are sent to Trustmark.
Trustmark Claim Forms – By State
The following Claim forms for Trustmark Health are used when you need to submit a claim. Click on the appropriate state.
Arizona
Iowa
Illinois
Indiana
Michigan
New Mexico
North Carolina
Ohio
Pennsylvania
South Carolina
Texas
West Virginia
Mail completed forms to the address listed on the back of your medical I.D. card.
Priority Health Prescription Form
On Priority Health’s website you can obtain mail order prescription forms such as:
Walgreens Healthcare Plus Registration and
Prescription Order Form
Walgreens Healthcare Plus Fax Order Form
All mail order prescription forms are sent or faxed to:
Walgreens
PO Box 628001
Orlando FL 32862-8001
Fax (800) 573-4719
Priority Health Change Forms
This Change Form for Priority Health is used when you need to add or delete dependents or change a name or address.
This Change Form for Priority Health is used when you need to change your PCP (Primary Care Provider).
Priority Health Member Reimbursement Form
The Member Reimbursement Form is used when a participant needs reimbursement for medical or prescription costs that they have paid out of their own pocket.
Priority Health Claim Form
The Claim Form for Priority Health is used when you need to submit a claim.
Priority Health Authorization for Release of Personal and Health Information
The Authorization is used when you need CSI Benefits Staff to assist you with a specific health or claim issue.
Priority Health Qualification Form
The Priority Health Qualification Form must be completed and submitted by your provider to Priority Health within 90 days of the member’s effective date with HealthbyChoice Incentives.
Life Conversion and Portability Forms
For the Basic Life Conversion form, click here
For the Basic Life Portability, click here
For the Optional Life conversion, click here
For the Optional Life Portability, click here
