Benefits Forms

Download the forms to complete them electronically or by pen.

 

Accident Claim Forms

Benefits Designation Form

Cancer, Specified Disease and Intensive Care Coverage Form

Cancer Wellness Form

Cancer Claim Form

Critical Illness Claim Form

Direct Rollover Request

Distribution Request

FSA Reimbursement Form

Group Life Conversion Application

Hardship Withdrawal Request

Health Plan Biometric Screening Form

Health Plan Lab Order Form

Health Plan Physical Form

Incoming Rollover Request

Kentucky Certificate of Nonresidence 

Lab Order Form

MASA Application

PTO Request Form

Survivor Benefit Request

Tuition Reimbursement Application

Wellness & Health Screening Form

Wellness Claim Form

Wellness Program Notice for ARH Employees

West Virginia Employee Withholding Exemption Certificate Form