Benefit Forms

All benefit forms are available for download.You will need Adobe® Reader® installed on your computer to view the benefit forms.

Adobe® Reader® 8 is free software that lets you view and print Adobe Portable Document Format (PDF) files on a variety of hardware and operating system platforms.

Carrier	Forms
Anthem Blue Cross	Anthem Enrollment/Change Form
	Dental Claim Form
	Group Family Health Statement
	Health Statement For Individuals Applying for Medicare Supplemental Plans H or J
	Mail Order Rx Form
	Medical Claim Form
	Prescription Drug Claim Form
	Termination Form

CBIA	CBIA Health Connections Enrollment/Change Form 3-50
	CBIA Health Connections 2 Enrollment Change Form 3-50
	CBIA Health Connections Family Health Statement 3-50
	CBIA Health Connections Group Application 3-50
	CBIA Health Connections Membership Application 3-50
	CBIA Health Connections Student Verification Form 3-50

Cigna	Member Claim Form
	Prescription Drug Claim

Connecticare	Enrollment Change Form
	Domestic Partner Verification
	Family Health Statement
	Individual Enrollment Package & Health Statement
	Mail Order Rx Form
	Small Group Information Change
	Small Group Employer Application
	Student Verification

Guardian	Enrollment/Change Form
	Dental Claim Form
	Medical Claim Form

Health Net	Health Net Change Cancellation Form
	Health Net Charter HMO Enrollment Form
	Health Net Charter POS Enrollment Form
	Health Net Passport HMO Enrollment Form
	Health Net Passport POS Enrollment Form
	Health Net Express Scripts
	Medical Claim Form
	Rx Claim Form

Oxford	Please contact your Broker or carolp@fwserra.com to obtain the correct form(s) needed for your Oxford Plan

If you are not finding the form(s) you need, please contact your Broker or carolp@fwserra.com to obtain the correct form(s) needed for your specific plan.