FORMS & DOCUMENTS

Medical form with stethoscope
forms
Pre-65 DOCUMENTS

GENERAL INFORMATION

2023 Guide to Benefits Cover Letter
2023 Guide to Benefits Book
2023 Premium Sheet
2023 Dental & Vision Premiums
POST 65 DOCUMENTS

GENERAL INFORMATION

2023 DSRABT COVER LETTER
2023 POST 65 Medical Rate Sheet
2023 Health Matters Post-65 Guide
2023 DENTAL PREMIUM POST 65
Hardship fund

Hardship Fund Application

2022 Pre-65 forms

BCBSM Open Enrollment Form 

IRS 13441A Form (HCTC Enrollment Form)

IRS 14095 Form

(Tax Return Reimbursement Form)

IRS 8885 Form (Reimbursement Form)

IRS 13973 Form (Blank Payment Voucher)

2022 post-65 forms

The BCBSM Medicare Advantage Enrollment Form 

The Hartford Enrollment Form (GRIP)

DSRA BT Enrollment Form

(dental & vision)

ALL MEMBERS
Guardian Beneficiary Designation Change Form
Pre-65 DOCUMENTS

GENERAL INFORMATION

2022 Guide to Benefits Cover Letter
2022 Guide to Benefits Book
2022 Premium Sheet
2022 Dental & Vision Premiums
POST 65 DOCUMENTS

GENERAL INFORMATION

2022 DSRABT COVER LETTER
2022 POST 65 Medical Rate Sheet
2022 Health Matters Post-65 Guide
2022 DENTAL PREMIUM POST 65
Dental & Vision Enrollment Form Post 65

CARRIER MATERIALS

BCBSM Gold 2022 SUMMAY OF BENEFITS
BCBSM SILVER 2022 SUMMARY OF BENEFITS
BCBSM BRONZE 2022 SUMMARY OF BENEFITS
BCBSM COPPER 2022 SUMMARY OF BENEFITS
BCBSM MEDICARE DISABLED PLAN BENEFITS

VISION

2022 VISION BENEFITS

DENTAL

CARRIER MATERIALS

THE HARTFORD PREMIUM CHART
THE HARTFORD ELITE BENEFIT CHART
THE HARTFORD PREMIUM PLUS BENEFIT CHART
THE HARTFORD CHOICE BENEFIT CHART

ENROLLMENT FORMS

Two forms are required for enrollment for The Hartford Plans

Benefit Enrollment Form Post 65
HARTFORD ENROLLMENT FORM
DENTAL AND VISION GUIDE
DENTAL LOW PLAN 2022
DENTAL HIGH PLAN 2022
MISC DOCUMENTS

MISC DOCUMENTS

HEALTH SAVINGS ACCOUNT

HSA FAQ'S

HARDSHIP FUND

HARDSHIP GRAND APPLICATION
CHIP MODEL NOTICE
WHCRA NOTICE

HELPFUL TOOLS

IRS 8885 FORM INSTRUCTIONS
SAMPLE 13441A ADDRESS CHANGE
SAMPLE 13441A NEW AMP ENROLLMENT
SAMPLE 13441A QFM

LIFE INSURANCE

GUARDIAN BENEFICIARY DESIGNATION CHANGE FORM
SAMPLE 13441A COVERAGE CHANGES

Open enrollment form

Copper Plan

IRS 13441A Form

Open Book