Benefit FORMS & DOCUMENTS | DSRA Benefit Trust

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FORMS & DOCUMENTS

Medical form with stethoscope

forms

BCBSM Open Enrollment Form

2024 Pre-65 forms

BCBSM Open Enrollment Form

2024 post-65 forms

The BCBSM Medicare Advantage Enrollment Form

The Hartford Enrollment Form (GRIP)

Dental and Vision Enrollment Form

2025 pre-65 forms

2025 post-65 forms

The BCBSM Medicare Advantage Enrollment Form

The Hartford Enrollment Form (GRIP)

Dental and Vision Enrollment Form

Pre-65 DOCUMENTS

GENERAL INFORMATION

2025 Guide to Benefits Cover Letter

2025 Guide to Benefits Book

2025 Premium Sheet

2025 Dental & Vision Premiums

POST 65 DOCUMENTS

GENERAL INFORMATION

2025 DSRABT COVER LETTER

2025 POST 65 Medical Rate Sheet

2025 Health Matters Post-65 Guide

2025 DENTAL PREMIUM POST 65

Hardship fund

Hardship Fund Application

ALL MEMBERS

Guardian Beneficiary Designation Change Form

CARRIER MATERIALS

BCBSM Gold SUMMAY OF BENEFITS

BCBSM SILVER SUMMARY OF BENEFITS

BCBSM BRONZE SUMMARY OF BENEFITS

BCBSM COPPER SUMMARY OF BENEFITS

BCBSM MEDICARE DISABLED PLAN BENEFITS

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

VISION

VISION BENEFITS

DENTAL

Benefit Enrollment Form Post 65

HARTFORD ENROLLMENT FORM

DENTAL LOW PLAN

DENTAL HIGH PLAN

MISC DOCUMENTS

MISC DOCUMENTS

HEALTH SAVINGS ACCOUNT

HARDSHIP FUND

HARDSHIP GRAND APPLICATION

CHIP MODEL 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

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