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.
- Coordination of Benefits Form
- Dependent Child Eligibility
- Disability Claim Form
- Extension of Weekly Disability Form
- Health Insurance Automatic Debit Form
- HIPAA Authorization Form
- HIPAA Appointment of Personal Representative
- HRA Claim Form
- HRA Premium Payment Form
- Newborn Election Form
- Prescription Out of Network Claim Form
- Vision Claim Form
- Contractor Participation Agreement
- Contractor Bonding Guidelines
- Contribution Rates (Effective 06/01/2020)
- Contribution Rates (Effective 06/01/2019)
- Declaration of Employer’s Authorized Representative
- Employer Contribution Form (PDF)
- Employer Contribution Form (Excel)
- Reciprocal Agreement
- i-Remit (Online Remittance Processing)