Member Forms and Information
Appeals Rights & Requests
Form Name | |
---|---|
Member Appeal Request Form | |
Right to Appeal Notice |
Group & Individual
Flexible Spending Account
Group Term Life
Form Name | |
---|---|
Death Benefits Claim Packet | |
Designation of Beneficiary Form | |
How to File a Life Insurance Claim | |
Group Life Insurance Claim Packet |
QCARE Health Management Programs
Form Name | |
---|---|
Diabetes Assessment Form | |
Hypertension Assessment Form | |
Maternal Health Appraisal Form | |
Maternity Notification Form |
MediQ65
Form Name | |
---|---|
MediQ65 Application for Coverage (to enroll in 2023 plans) | |
MediQ65 Payment Authorization Form | |
Notice of Replacement Questionnaire |
Employer Forms and Information
Contacts
Sales and Service Team Contacts |
Information
ATNE Worksheet | |
Healthy Weight Wellness Challenge | |
Medicare Part D Notice for Employers | |
Products and Services Brochure | |
Stress-Free Me Challenge | |
Where to Go For Care - ES |
Groups
Flexible Spending Account
Group Term Life
Form Name | |
---|---|
Death Benefits Claim Packet | |
Designation of Beneficiary Form | |
How to File a Life Insurance Claim | |
Group Life Insurance Claim Form | |
Group Life Insurance Claim Packet |
Broker Forms and Information
Contacts
Sales and Service Team Contacts |
Information
ATNE Worksheet | |
Deductible and OOP Credit Information Flyer | |
Products and Services Brochure | |
Stress-Free Me Challenge | |
Where to Go For Care - ES |
Broker/Agent Forms
Flexible Spending Account
Groups and Individual
Group Term Life
Form Name | |
---|---|
Death Benefits Claim Packet | |
Designation of Beneficiary Form | |
How to File a Life Insurance Claim | |
Group Life Insurance Claim Form | |
Group Life Insurance Claim Packet |
MediQ65
Form Name | |
---|---|
MediQ65 Application for Coverage (to enroll in 2022 plans) | |
MediQ65 Application for Coverage (to enroll in 2023 plans) | |
MediQ65 Payment Authorization Form | |
Notice of Replacement Questionnaire |