Forms & Publications for the Group Dental Insurance Plan

Documents in this section require Adobe Acrobat Reader® for viewing. The reader is available as a free download from Adobe Systems, Inc. In addition, you may wish to consult the " .pdf help page" for instructions on printing or saving an Adobe Acrobat (.pdf) document.

Forms for All Members

• Physician's Form for Handicapped Dependent (SFN-58798)
• Application for Dependent Disability (SFN-58856)
• Notice of Change - Member Data Record (SFN 10766)

Forms for Active Members & Dependents

• Dental/Vision Insurance Application or Change (SFN-58792) ( for Active Members)
• Continuation of Group Insurance Coverage - COBRA (SFN 14120) (for Active Members & Dependents)

Forms for Retirees

• Retiree Dental/Vision Insurance Application/Change (SFN 53504)
• Employer Verification of Insurance Coverage (SFN 53621)
• Authorization for Premium Deduction (SFN 50134)
• TFFR Payroll Deduction Authorization (SFN 19182)
• Verification of Alternate Retirement Plan (SFN 53863)

Publications

• Summary Plan Description
• Rates