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Insurance Forms


Following are various forms you may download and submit to the Insurance Department.

Employee Assistance Program Supervisor Referral Form
This is the form supervisors use to make a mandatory referral to the EAP.

Change of Address Form

Flexible Spending Account Application

Student Accident/Incident Report
This is the form to be completed with a student or campus visitor is injured on campus. Completed forms should be turned into the Insurance Department.

Legal Shield Application
Use this form to enroll in identity theft protection plan and/or coverage for legal services.

Health Plan Selection Form
Use this form to select a different plan option.  Choose from the Basic PPO, the Enhanced PPO, or the High Deductible Health Plan. 

HSA Change Form
Use this form to request a change in the amount you deduct from your check to be deposited into your HSA if your account is at Iberia Bank.  You can change this deduction any time during the year.  If your account is at the Credit Union, you must go to their location to make a change.

PRESCRIPTION DRUG CLAIM FORMS                                                     

Express Scripts Prescription Drug Mail Order Form Order a 90-day supply of your maintenance medication with this form.  This form should be mailed to Express Scripts, Mail Pharmacy Service, PO Box 52123, Phoenix, AZ 85072-2123.

BLUE CROSS BLUE SHIELD FORMS

Health Plan Enrollment Form   This is the form you must complete to enroll in the health plan if you are not currently enrolled.

Dependent Certification Form   This is a Blue Cross Blue Shield form used to verify that your dependent child over the age of 21 is a full-time student.                                             
                           

Blue Cross Blue Shield coverage cancellation form .

Blue Cross Blue Shield Claim Form   This is the claim form used to file your medical claims.      

Authorized Delegate Form  This is the form employees on the health plan may complete and submit to Blue Cross to give Blue Cross permission to share protected health information with others, such as a family member or the Insurance Department staff.  You must provide this written permission to Blue Cross if you want the Insurance Department staff or a family member to get information on your claims.  Without this written permission, HIPAA prevents Blue Cross from speaking to anyone about your health information.

Other Coverage Questionnaire   This is a form BCBS occasionally requests employees complete when they are checking for other coverage available to a plan member.  That information is needed for coordination of benefits.

LIFE INSURANCE FORMS   

Beneficiary Designation Form   Use this form for your initial selection of your life insurance beneficiaries or to change your beneficiary designations.  

Life insurance enrollment form  Use this form to enroll in life insurance.                           

VOLUNTARY BENEFITS

 For information regarding voluntary benefits such as disability coverage, vision, and dental visit First Financial Group of America .