Forms marked with an asterisk * are fillable. That means you can complete the form on your computer. Once complete, print and sign the form and send it to the Plan.
You will need Adobe Acrobat Reader to view and complete any forms. These forms work best with Google Chrome or Firefox web browsers.
Check out our helpful checklists and forms below:
Employer's Statement - Page 1* (Employer must complete both Page 1 and 2)
Employer's Statement - Page 2* (Employer must complete both Page 1 and 2)
Attending Physician's Statements
The group plan number for the following forms is 57402.