Forms

These forms require Adobe Acrobat.

Flexible Benefits Forms and Brochures

• Change Form
• Claim for Reimbursement
• Dependent Care Brochure
• Dependent Care Enrollment Form
• Direct Deposit- Authorization Agreement
• Flex Convenience Enrollment Form
• FSA Medical Expense Checklist
• Medical Expense Worksheet
• Medical Spending Brochure
• Medical Spending Enrollment Form
• Medical Spending with Flex Convenience Card Brochure
• Over-the-Counter Drug Chart
• Premium Payment Brochure
• Premium Payment Enrolment Form

• Accelerated Death Claim Form
• Accidental Death Claim Form
• Conversion Claim Form
• Death Claim Form
• Employer Group LTD Trust Participation Application & Agreement
• Evidence of Insurability Form
• LTD Applicaton
• LTD Claim Form
• Master Applicaton
• STD Attending Physicians Statement
• STD Disability Claim Form
• VADD – Group Accident Claim
• W – 2 Agreement Form 2007 (MS Word)
• W – 2 Agreement Form 2008 (MS Word)
• Wavier of Premium Claim Form

• Beneficiary Form
• Conversion Application
• Death Claim Form
• Disclosure
• Evidence of Insurability Form
• Group Master Application
• LTD Claim Form
• Multipurpose - Waiver of Premium Claim Form, STD Claim Form, Accidental Dismemberment, Accelerated Death
• W-2 Agreement Form

BlueCross BlueShield of Tennessee Forms

• APP-EEW Employee Enrollment/Waiver Form
• APP-ADC Add Dependent/Change Request Form
• BCBST APP-TRM - Termination Form

DCAP Information

• DCAP vs. Tax Credit
• DCAP vs. the Dependent Care Tax Credit
• Calculate Credit vs. DCAP
• Participant letter

Please contact Group Insurance Services at info@gisbenefits.com for additional information.