Traditional Self Funding
Accident Questionnaire-Spanish
Authorized Representative Form
Authorized Representative Form - Spanish
Benefits Enrollment/Change Form
Benefits Enrollment/Change Form-Spanish
Coordination of Benefits Form-Spanish
COVID-19 Testing Member Reimbursement Form
Mail Order Prescription Form (Optum Rx)
Mail Order Prescription Form (Optum Rx)-Spanish
Medical Benefits Short-Term Disability Claim Form
Medical Benefits Short-Term Disability Claim Form-Spanish
Prescription Reimbursement Request Form
Level Funding
Level Funded Automated Risk Assessment
Level Funded Employer Application
This product is not available in the state of South Carolina