Benefit Forms

For your convenience, we are providing you with online forms that you need for optical, dental and medical services. Just click on the form you need and print it out and bring it with you to the service provider.

CLICK HERE FOR THE 2023 W&C FUND SCHOLARSHIP APPLICATION

• CLAIM FORM (IN STATE)
• CLAIM FORM (OUT OF STATE)
• MEDICARE PART D SECONDARY CLAIM FORM
• MANDATORY GENERIC SUBSTITUTION APPEAL FORM
• SCRIPT ENROLLEE CLAIM SUBMITTAL FORM

• DENTAL PROVIDER NOMINATION REQUEST
• HEALTHPLEX CLAIM FORM
• HEALTHPLEX DENTAL CARE CLAIM FORM
• DEPENDANT STUDENT CERTIFICATION FORM

• COUNTY CLAIM VOUCHER COURSE REIMBURSEMENT
• COBA COURSE REIMBURSEMENT FUND
• COURSE REIMBURSEMENT FORM

• RATE SHEET
• SUPPLEMENTAL LIFE INSURANCE- EMPLOYEE
• BASIC LIFE INSURANCE POLICY
• SUPPLEMENTAL LIFE INSURANCE POLICY

• COBA MOA 38-10 TERMINATION PAY
• TERMINATION PAY BENEFICIARY FORM
• TERMINATION PAY BENEFICIARY LETTER