Benefits Administration

Insurance Forms

All files on this page are in Adobe Acrobat format. As a convenience, the PDF forms allow you to fill in the requested information before printing. After filling in the necessary information you may print out the form, sign in the requested fields, and send the form to your agency benefits coordinator (typically located in the human resource section of your department). Please note: The data you fill out on these forms is NOT submitted electronically to your benefits coordinator. A printed form must be submitted to your agency to process any requested changes.

NEW — Enrollment/Change Application — Retiree Dental Coverage (FA-1032)
Be sure to review the Dependent Eligibility Verification Document to determine what documents must be submitted for you to enroll your dependents in coverage

Enrollment/Change Application—State and Higher Education (FA-0820)

Enrollment/Change Application—Local Education (FA-0854)

Enrollment/Change Application—Local Government (FA-0978)

Enrollment/Change Application—Dependent Eligibility Verification Documents
Provides a list of acceptable documentation which must be submitted effective July 1, 2009, to enroll an eligible dependent in coverage

Request for Extension to Submit Eligibility Documentation
To be used by those who need additional time to secure dependent eligibility documentation

Basic Life Beneficiary Designation Application (FA-1005)

Application for Special Enrollment by Qualifying Event (FA-0868)

Application for Late Enrollment — Medical Underwriting
Please note: Effective June 1, 2009, the application fee for medical underwriting increased to $75

Application to Continue Insurance at Retirement TCRS (TR-0221)

Application to Continue Insurance at Retirement non-TCRS (FA-0857)

Application for Medicare Supplement TCRS (TR-0395)

Application for Medicare Supplement non-TCRS (FA-0983)

Request for Retroactive Transaction (FA-0938)

Leave Without Pay—State and Higher Ed (FA-0867)

Leave Without Pay—Local Education and Local Government (FA-0953)

Optional Special Accident Enrollment Application (FA-0831)

Optional Term Life Enrollment Application (M-95201)

Optional Universal Life Enrollment Application (M-95090)

Optional Life Supplemental Application (M-95202)

Optional Life Customer Service Request Form (L-52490)