Forms & Documents
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Disability Insurance - The Standard
Federal & State Required Notices
- Consolidated Omnibus Budget Reconciliation Act (COBRA)
- Creditable Coverage Disclosure Notice
- EEOC Wellness Program Notice
- Family & Medical Leave Act (FMLA)
- Genetic Information Nondiscrimination Act (GINA)
- Health Insurance Portability & Accountability Act (HIPAA)
- Marketplace Model Notice
- Mental Health Parity Act
- Michelle's Law
- Newborns' and Mothers' Health Protection Act
- Notice of Privacy Practices (January 2022)
- Patient Protection & Affordable Healthcare Act (Health Care Reform)
- Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
- Women's Health & Cancer Rights Act/Masectomy Reconstruction
Florida Retirement System
- Application for Disability Retirement Packet
- Application for Service Retirement
- Application to Purchase Retirement Credit for a Pension Plan Leave of Absence (FR-28)
- Application to Reactivate Retirement Benefits (FRT-23a)
- Beneficiary Designation Form for Active Pension Plan Members Only (BEN-001)
- Beneficiary Designation Form for Retired Pension Plan Members and DROP Participants (FST-12)
- DROP Application Packet
- Investment Plan Employment Termination Form (ETF-2)
- Notification of Reemployment for Suspension of Retirement Benefits (FR-23)
- Request for Information (FR-9)
- Statement of Military Eligibility (MF-1)
- Statement of Military Eligibility to Purchase Military Service Under the Out-of-State Provisions (MF-2)
- Verification for In-State or Out-of-State Service Credit (FR-30)
Hospital Indemnity
- Trustmark Hospital Indemnity Flyer (Effective 1/1/23)
- Trustmark Wellness Claim Form (Effective 1/1/23)
- Trustmark Hospital Claim Form (Effective 1/1/23)
- Trustmark Claim Instructions (Effective 1/1/23)
- Allstate Hospital Claim Form (Prior to 2023)
- Allstate Hospital Claim Instructions (Prior to 2023)
- Allstate Outpatient Physician Treatment Claim Instructions (Prior to 2023)
- Allstate Outpatient Treatment Claim Form (Prior to 2023)
Medical - Allegiance
- 2024 Summary of Benefits and Coverage (Effective 1/1/24) - Enhanced
- 2024 Summary of Benefits and Coverage (Effective 1/1/24) - Custom
- 2024 Summary of Benefits and Coverage (Effective 1/1/24) - Basic
- Cigna LifeSOURCE - Amendment 13
- Special Enrollment Period - Amendment 12
- End of COVID-19 Public Health Emergency - Amendment 10
- Termination of Coverage - Amendment 9
- Summary Plan Description (eff. 1/1/22)
- 2023 Summary of Benefits and Coverage (Effective 1/1/23) - Basic
- 2023 Summary of Benefits and Coverage (Effective 1/1/23) - Custom
- 2023 Summary of Benefits and Coverage (Effective 1/1/23) - Enhanced
- Abortion Compliance Amendment
- Affidavit of Dependent Eligibility
- Medical Claim Form
- No Surprises Act 2022
- Summary of Material Modifications Extending COVID-19
- Summary of Material Modifications Related to COVID-19
- Telemedicine Amendment
