US Insurance Plan Forms

NOTE:  Enrollment Forms for all eligible employees must be received in the CSI Employee Benefits office within 30 days from date of hire. Also, changes to coverage must be made within 30 days of a life event or during open enrollment. 

 


 

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. This form must be submitted to the CSI Employee Benefits office within 30 days from date of hire. 

 


 

Optional Life Application Form

The Optional Life 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 our insurance plan.
If applying more than 30 days past your date of hire, or if spouse coverage greater than $50,000 is desired, Personal Health Application will also need to be filled out. 

 


 

Beneficiary Change Form - Hartford

The beneficiary change form is used to change the beneficiary on the active participant’s life insurance policy. 

 


 

Life Continuation of Coverage Form

  • The Life Continuation of Coverage Form is used when you terminate your active status and would like to continue your term life insurance (basic life and/or optional life).

You will need to print the form and mail it to:

The Hartford, Portability and Conversion Unit
P.O. Box 248108
Cleveland, OH 44124-8108
Fax: 1.440.646.9339

 


 

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.

 


 

Employee Application and Change Form (for Priority Health schools only)

The Employee Application and Change form is used to add a new hire, add or delete dependents for health, life, AD&D, LTD, dental and change plans. Choose one of the following forms based on the size of your school. NOTE:  Enrollment forms for new hires must be submitted to the CSI Employee Benefits office within 30 days from date of hire. 

 


 

Priority Health HealthbyChoice Incentives (HBCI) Qualification Form

The Priority Health HBCI 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.

 


 

Priority Health Member Reimbursement Form

 


 

Priority Health Express Scripts Mail Order Prescription Link

  • Priority Health is using Express Scripts for mail order prescriptions. 

 


 

Priority Health Authorization for Release of Personal and Health Information

  • The Authorization is used when you need our Benefits Staff to assist you with a specific health or claim issue.

 


 

Priority Health Claim Form

The claim form for Priority Health is used when you need to submit a claim.