Important Benefits Forms

Health Insurance Forms

BCBS Enrollment, Change, Waiver Form Eligible Clergy & Laity Enroll in coverage, add a dependent, change address, change name, waive initial coverage
Coverage Cancellation Form​ Covered Clergy & Laity Drop a dependent from health insurance plan

United Concordia Dental Claim Form

United Concordia Claim Instructions

Covered Clergy & Laity For expenses incurred with non-network dentist (network dentist file for you)

BCBS Medical/Vision Claim Form
BCBS Prescription Claim Form

Covered Clergy & Laity File a claim with BCBS for medical, vision, and/or prescription expenses
Church Benefits Authorization [EFT] Church Finance Staff Authorize payments directly from church bank account for Benefits bill
LAUMC- Retiree/Spouse Health premium Deductions Authorization​ Retired Clergy
Surviving Spouse
Authorize the General Board of Pension & Health Benefits to deduct the health insurance premium from pension check
     


Health Savings Account Forms

 

Additional Deposit Form Church Finance Staff Send clergy payroll withholding for HSA to AHR
Change Form Eligible Clergy & Laity Make changes in address, name, contribution amounts
Claim Form Eligible Clergy & Laity Send in claims to be paid on the account (can also be done on-line)
Eligibility For Contributions Eligible Clergy & Laity Annual verification of eligibility to participate in an HSA
Enrollment Form Eligible Clergy & Laity Clergy or laity covered by the health insurance enrolling for an HSA

 

Pension Forms

 

Contribution Election Eligible Clergy & Laity Specify UMPIP contribution amounts
Church Benefits Authorization [EFT] Church Finance Staff Authorize payments directly from church bank account for Benefits bill
Designation of Beneficiary for Retirement/Welfare Participant Eligible Clergy & Laity

Name a beneficiary to receive retirement and other Wespath benefits in the event of participants death

Enrollment Form for Clergy and Laity

Eligible Clergy & Laity

Clergy and Laity enrolling in UMPIP,  CRSP, CPP
Waiver Of Participation [CRSP] Eligible Clergy To waive participation in CRSP by a clergy person serving less than full time
Waiver Of Participation [UMPIP] Eligible Clergy For ¼ time clergy to waive participation in UMPIP 

 

 

 

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