Important Forms

We try to do as much as we can online, but there will always be forms to deal with.
Here is a collection of links to the most important forms relating to your benefits.

 

Form Who it's for What it's for

 

Pension Forms  

UMPIP Contribution Election Form

 

Eligible clergy and laity

 

Specify Before-tax, Roth, and After-tax personal contribution amounts to UMPIP

 

Beneficiary Designation for Retirement and Welfare Plans – Participant

 

Eligible clergy and laity

 

 

Name a beneficiary to receive retirement benefits in the event of participant's death

 

 

Church EFT Pension Authorization Form

 

Church financial personnel

 

Authorize payments directly from church bank account for clergy pension contributions

 

CRSP/UMPIP/CPP Enrollment

 

Eligible clergy

 

Enroll in CRSP, UMPIP, CPP

 

UMPIP Enrollment

 

Eligible laity

 

Enroll in UMPIP

 

 

Group Health Benefits Forms  

TAC Group Health Benefits Enrollment Form

 

  • New clergy

 

  • Newly eligible TAC lay employees

 

  • Eligible clergy and lay employees during open enrollment

Enrolling in group health benefits

 

TAC Group Health Benefits Change Form

 

Eligible clergy and lay employees

 

Make qualified changes outside of the Annual Open Enrollment Period, such as a change of name or address, adding dependent coverage within 30 days of a qualified life event (e.g. birth, adoption, marriage, or loss of other coverage), or termination of dependent coverage

 

TAC Group Health Life Insurance Beneficiary Update Form

 

Eligible active and retired clergy and lay employees

 

Update beneficiaries for employee group health life insurance benefit through American United Life (AUL)

 

Boon-Chapman Annual Additional Insurance Form

 

All Group Health Plan employee participants

 

Confirmation of additional insurance coverage

 

Boon-Chapman Medical Claim Form

 

Group Health Plan participants

 

Reimbursement of out-of-network claims and/or out-of-pocket expenses

 

EFT - Church Group Health Plan Authorization Form

 

Church financial personnel

 

Authorize payments directly from church bank account for clergy health coverage

 

EFT - Medical Leave Group Health Authorization

 

Eligible clergy on medical leave

 

Authorizes payments from your bank account for your Group Health contributions

 

EFT – Retiree/Surviving Spouse Group Health Authorization form

 

Eligible retirees and surviving spouses

 

Authorizes payments from your bank account to maintain Group Health coverage

 

Adoption Reimbursement Form

 

Active clergy and lay employee participants in the Group Health Plan

 

Expenses incurred in the adoption of a child

 

Hearing Aid Benefit Reimbursement Form

 

Active clergy Group Health Plan participants

 

Reimbursement of eligible hearing aid expenses

 

Retiree Taxable Stipend form

 

Retirees age 65 and older

 

Application for taxable stipend

 

 

Wellness Program Forms  

2016 A-la-carte Fitness Rebate Form

 

All Wellness Program participants

 

Apply for a 50% refund for Health and Wellness purchases and fees paid from January 1 through September 30, 2016

 

Wellness Program Incentive Form

 

All Wellness Program participants

 

Submit to request Wellness Incentives

 

Physician Confirmation Form

 

All Wellness Program participants

 

Wellness Incentives that require physician authorization

 

Annual Maintenance Incentive Form

 

All Wellness Program participants

 

Submit for Annual Wellness Program maintenance incentives

 

Pregnancy Weight Loss Incentive Form

 

All Wellness Program participants

 

Submit request for pregnancy weight loss incentive

 

Prior Weight Loss Wellness Incentive Form

 

All Wellness Program participants

 

Submit to request incentive for weight loss prior to the Day of Wellness

 

Bariatric Surgery

Requirements and Checklist Package

 

Commitment Form

Group Health Plan participants

 

 

Requirements and procedures for bariatric surgery benefit

 

 

 

 

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