Administrative Forms

	EGYPTIAN AREA SCHOOLS EMPLOYEE BENEFIT TRUST
Administrative Forms

Administration Meeting Presentations Now Available

All Forms are in PDF format. You will need Adobe Reader to view the forms.

It can be downloaded here.

Employee Forms

Enrollment Form - All Products

Enrollment Form - Changes Only

Enrollment Notice - 12 month notice to change health plan

Dependent Status Form

Member Statements Form

MyMeritain Member Website

Employer Forms

Employer - Individual Selection Form (must be completed every August 1st)

Employer - Contact Change Form

Claim Forms

Dental Claim Form

Medical Claim Form

Prescription Drug Claim Form

Medical Plans

HIPAA Privacy Practices

Schedule of Benefits - Platinum

Schedule of Benefits - Gold

Schedule of Benefits - Silver

Schedule of Benefits - Bronze

2010 Preventive Care Drug Listing - Bronze

2010 Drug Formulary

Life Insurance

Optional Life Insurance Brochure

Evidence of Insurability Form

Life Claim Form

Group Life Conversion Brochure

Continuation of Coverage Form

Portability Application

Extension Of Death Benefits Application

Dental

Dental Summary of Benefits

Vision

Summary of Benefits – Vision

Vision Out of Network Claim Form

UniView Vision Benefits Brochure

Healthy Extensions Flyer