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FORMS & DOCUMENTS

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forms

LIFE INSURANCE

2027 pRE-65 forms

BCBSM Open Enrollment Form 

Form for all Medical Plans, Dental & Vision

2026 pRE-65 forms

BCBSM Open Enrollment Form 

Form for all Medical Plans, Dental & Vision

Pre-65 DOCUMENTS

GENERAL INFORMATION

2027 post-65 forms

Medicare Enrollment Form

Form for Medicare Advantage, Hartford,

Dental & Vision, PDP Plans

The Hartford Enrollment Form (GRIP)

Hartford Form and Enrollment Form both required for enrollment

2026 post-65 forms

Medicare Enrollment Form

Form for Medicare Advantage, Hartford,

Dental & Vision, PDP Plans

The Hartford Enrollment Form (GRIP)

Hartford Form and Enrollment Form both required for enrollment

POST 65 DOCUMENTS

GENERAL INFORMATION

ALL MEMBERS

CARRIER MATERIALS

CARRIER MATERIALS

ENROLLMENT FORMS

Two forms are required for enrollment for The Hartford Plans

VISION

DENTAL

HARDSHIP FUND

Hardship fund

Hardship Fund Application

MISC DOCUMENTS

MISC DOCUMENTS

Open Book

Open enrollment form

Copper Plan

IRS 13441A Form

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Stay Informed!  Please click here to sign up for the Eblast 

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Benistar DSRA Benefit Trust Customer Service/Call Center

1-888-588-6682

DSRA Benefit Trust website  

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