Benefits Forms Health Benefits Union Trust Enrollment Type Name Local 935 Fire Trust Enrollment Acknowledgement Form SEBA Union Trust Enrollment Acknowledgement Form Teamsters Trust Enrollment Acknowledgement Form Medical Type Name Blue Shield Prescription Order Blue Shield Prescription Order – FAX Bronze Plan Enrollment Form Declination Agreement for Essential Health Plan Coverage Dependent Medical Plan Social Security Number Collection Form Disabled Dependent Certification Medical Plan Enrollment/Change Opt-Out/Waiver Election Agreement for Medical and/or Dental Premium Deduction Election PPACA Marketplace Notice Dental Type Name Delta Dental Claim Form (DPPO) – Out of Network Delta Dental Claim Form (DHMO) – Out of Network Dental Plan Enrollment/Change Disabled Dependent Certification Opt-Out/Waiver Election Agreement for Medical and/or Dental Premium Deduction Election Vision Type Name Disabled Dependent Certification Premium Deduction Election Vision Out-of-Network Claim Vision Plan Enrollment/Change – Eligible Units Cobra Type Name COBRA Medical Plan Enrollment/Change COBRA Dental Plan Enrollment/Change COBRA Vision Plan Enrollment/Change Life Insurance Type Name Life Insurance and AD&D Enrollment Securian Life Insurance (County Sponsored) Group Universal Life Insurance Enrollment (Exempt Group Only)
