Forms

• Waiver of Premium Procedure

• Claim Form - Medical Expense
• COBRA (continuation coverage and other health coverage alternatives)
• Request for Automatic Deduction of Health Insurance Premium
• Direct Reimbursement Vision Claim
• Domestic Partnership Declaration Statement
• ProAct Direct Member Reimbursement Form
• Prescription Coordination of RX Benefits Claim
• ProAct Mail Order Enrollment Form
• Termination of Domestic Partnership
• Vision Care Claim
• Young Adult Insurance Coverage Affidavit
• Flexible Spending Account Reimbursement Request Form


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