Forms

Forms

Form Name Description Form Category Download
Certificate of Creditable Coverage Form for continuation of coverage HRA
Change in Age for Children Form for dependent chilrden age 19-26 HRA
Change of Address Form to update Fund Office of current address 401K, HRA, Pension Plan
Claim Form HRA
Claim Form - Recurring and Third Party To file for recurring claims payable to a third party HRA
Continued Coverage for Disabled Child HRA
Dependent Change Form Form to add dependents HRA
Direct Deposit Authorization Package Form to elect or change direct deposit information for pension payments 401K, HRA, Pension Plan
HRA - Opt Out Form HRA
HRA -Attestation Form HRA
HRA Enrollment Form HRA
HRA Forms Please find HRA Forms on the HRA Account Login Page. To get there, hover over the LOGIN menu option and select HRA Account Login. HRA
HRA Major Medical Coverage Attestation Form HRA
Legal Name Change Form HRA
PHI Release Form Authorization to release personal health information HRA

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