Forms & Documents
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Accident Insurance- Trustmark (For claims prior to 1/1/19)
Federal & State Required Notices
- Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
- Consolidated Omnibus Budget Reconciliation Act (COBRA)
- Family & Medical Leave Act (FMLA)
- Genetic Information Nondiscrimination Act (GINA)
- Health Insurance Portability & Accountability Act (HIPAA)
- Mental Health Parity Act
- Michelle's Law
- Newborns' and Mothers' Health Protection Act
- Patient Protection & Affordable Healthcare Act (Health Care Reform)
- Privacy Policy
- 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 - Allstate
Medical - Allegiance
- 2021 Summary of Benefits and Coverage (Effective 1/1/21) – Basic
- 2021 Summary of Benefits and Coverage (Effective 1/1/21) – Custom
- 2021 Summary of Benefits and Coverage (Effective 1/1/21) – Enhanced
- 2020 Summary Plan Description (Effective 3/1/20)
- Summary Plan Description Amendment #1 (Effective 8/1/20)
- Summary Plan Description Amendment #2 (Effective 7/1-12/31/20)
- Summary of Material Modifications Related to COVID-19
- 2020 Summary of Benefits and Coverage (Effective 1/1/20) - Enhanced
- 2020 Summary of Benefits and Coverage (Effective 1/1/20) - Custom
- 2020 Summary of Benefits and Coverage (Effective 1/1/20) - Basic
- Medical Claim Form
- Affidavit of Dependent Eligibility
