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. To obtain this form you can call CSI Benefits office 1-877-274-8796, Ext 233.




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.




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 - Hartford

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 Wellpoint Prescription Form

To obtain Trustmark Wellpoint Prescription Forms, go to http://www.Caremark.com.




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.




Priority Health Prescription Form

Priority Health is using Express Scripts for mail order prescriptions. 

To learn more about mail order prescriptions you can obtain the information by clicking here.




Priority Health Change Forms




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 Continuation of Coverage Form