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Health Forms

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CIGNA Health Claim Form

Use this form to submit a claim for CIGNA under the Indemnity Plan.

CIGNA Prescription Claim Form

Use this form to submit a claim for CIGNA Prescriptions.
Dental Out of Network Claim Form

Use this form for out-of-network providers. In-network providers will bill CIGNA Dental directly.

Davis Vision Out of Network Claim Form

Use this form for out-of-network providers. In-network providers will bill Davis Vision directly.

Dependent Coverage Form

Use this form to enroll eligible dependents for medical and vision coverage.

Domestic Partners Affidavit For Health Fund

In order for an eligible domestic partner to qualify for health benefits under the Plan, an application must be submitted along with the required documentation and premium notice.

NY COBRA Subsidy Program Effective January 1, 2005

Please complete this application for the New York State COBRA Subsidy Program

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