Forms

Here are forms you may need for your benefit coverage.

Accident and Sickness Weekly Income Benefit Claim
Open the Form
Affidavit of Qualifying Incapacitated Dependent Eligibility
Open the Form
Change of Address
Open the Form
Enrollment: Active Employee Plan – English
Open the Form
Enrollment: Active Employee Plan – Spanish
Open the Form
Express Scripts Prescription Drug Reimbursement Claim Form
Open the Form
Regence Authorization to Disclose Protected Health Information
Open the Form
Regence Member Reimbursement Claim Form - English
Open the Form
Regence Member Reimbursement Claim Form – Spanish
Open the Form
Retiree and Surviving Spouse Coverage Information
Open the Form

Not finding the form you need? Please contact the Trust Administrative Office for assistance.

This website provides an overview of the Plan benefits for Active Employees and non-Medicare Retirees. Please refer to your Active Employee Plan Summary Plan Description (SPD) or Retiree Plans Summary Plan Description (SPD) for benefit details. If there is a conflict between the information provided on this website and the official Plan documents, provisions of the official Plan documents will govern how the Plans work and how the Plans pay benefits.

If you are a Medicare-eligible Retiree who is enrolled in the Trust’s fully-insured Plan through Regence, please click here to learn more about your Plan benefits.

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