|Dental Claim Form||Download|
|BCBS Claim Form||Download|
|BCBS HIPAA Authorization||Download|
|BCBS Rx Claim Form||Download|
|BlueCard Worldwide International Claim Form||Download|
|Prime Speciality Order Form||Download|
|PrimeMail Order Form||Download|
|HRA - Health Reimbursement Arrangement|
|Lucent Health HRA Direct Deposit Form||Download|
|Lucent Health HRA Reimbursement Form||Download|
|HSA - Health Savings Account|
|HSA Account Closure Form||Download|
|HSA Beneficiary Designation Form||Download|
|HSA Enrollment Verification Form||Download|
|Empower Beneficiary Form||Download|
|Tax Form 1095-C||View Details|
|Biometric Screening Certification Form||Download|
|Wellness Program Appeal||Download|
|Well-being Reimbursement Instructions & Form||Download|
If you need a form not listed here, please contact Human Resources to request it.
The information on this page is a partial description of benefits, limitations, exclusions, and other provisions of the group benefits provided by Woodmen of the World Life Insurance Society (WoodmenLife). If there is a difference between the information in this summary and the plan document for each plan, the plan documents govern. Eligibility requirements apply to each of the benefits offered, criteria may include employment status and/or individual qualifications. For more detailed information, refer to the Summary Plan Description of each plan. WoodmenLife may amend these plans at any time. The description of the plan is not a guarantee of benefits and should not be construed as such.
This is the Life is a registered service mark of Woodmen of the World Life Insurance Society.