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. This form is also used to 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 or from date of coverage change.
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
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.
when you have the vision coverage.
Employee Application and Change Form (for Priority Health schools only)
The Employee Application and Change form is used to add a new hire. This form is also used to add or delete dependents for life, AD&D, LTD, dental, or to change coverage. 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 or from date of coverage change.
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.
- Tobacco use: non-user of tobacco, verified in the last 6 months
- Body mass index, BMI of less than 30, verified in the last 6 months
- Blood pressure: under 140/90, verified in the last 6 months
- LDL cholesterol: under 160, verified in the last 5 years
- Blood sugar: not required for health participants, for diabetics HbA1c must be < 8% every year
- If you do not qualify, you will stay at the HBCI-Standard level
- You can try again for the HBCI-Choice level at any time
- Participants may also qualify by making measurable health improvements or by reaching target set by provider
Priority Health Member Reimbursement Form
Priority Health Express Scripts Mail Order Prescription Link
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.
Adoption Expense Claim Form
The insurance plan will reimburse for certain adoption expenses.