Insurance Forms

The following downloads are PDF files. They are easily viewed and printed on any computer with Acrobat® Reader installed. A free version of Acrobat® Reader can be downloaded from www.adobe.com. 

Are you a NEW EMPLOYEE who has been hired within the last 31 days? If so, you are within your initial enrollment period! Enroll now! Click here for the New Employee insurance enrollment packet.

Notice of Privacy Practices

Authorization Agreement for Automatic Payment 

New Employee Insurance Enrollment Packet

Insurance Enrollment Form (Employer Group)

Insurance Enrollment Form (Ministers' Group)

Brethren Medical Plan

BMP Employee Application

Wellness Program Election Form

Dental

Delta Enrollment Form

Vision

EyeMed Enrollment Form

Medicare Supplement

Medicare Supplement Plan Summary of Benefits

Medicare Supplement Plan Enrollment Form

FlexCare

Account Withdrawal Request

Election Form and Salary Reduction Agreement (Employer Group)

Election Form and Salary Reduction Agreement (Ministers' Group) 

Election Instructions (Employer Group)

Election Instructions (Ministers' Group)

Long-Term Disability/Life Insurance

LTD Budget Worksheet

STD Budget Worksheet

Basic & Supplemental Life Designation of Beneficiary 

Supplemental Life Enrollment Form

Retiree Life Insurance Enrollment Form

Student Verification Form

Evidence of Insurability Form

Long-Term Care Insurance

Long-Term Care Insurance Proposal Request