Below are commonly used forms. If you need to update your dependent information due to a qualifying event, or change in your family status such as marriage, divorce, birth or adoption of a child, or other changes to your dependent family members please notify us at the Benefit Trust Office at 937-454-1744 or via email.
- Beneficiary Designation Form – English
- Beneficiary Designation Form – Spanish
- Disability Claim Form
- Enrollment Form – English (printable form)
- Enrollment Form – English (online form)
- Enrollment Form – Spanish (printable form)
- Extension of Weekly Disability Form
- Health Insurance Automatic Debit Form
- HIPAA Authorization Form
- HIPAA Appointment of Personal Representative
- HRA Claim Form
- Newborn Enrollment Form (printable form)
- Newborn Enrollment Form (online form)
- Prescription Out of Network Claim Form
- VSP Out of Pocket Claim Form
- Contractor Participation Agreement
- Contractor Bonding Guidelines
- Contribution Rates (Effective 08/01/2024)
- Contribution Rates (Effective 06/01/2024)
- Contribution Rates (Effective 01/01/2024)
- Declaration of Employer’s Authorized Representative
- Reciprocal Agreement (Online form)
- Reciprocal Agreement (Printable PDF form)
- i-Remit (Online Remittance Processing)