Document

What it's for...

Who it's for...

Retirement Benefits 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

Group Health Benefits (GHB) Forms
TAC GHB Enrollment Form New clergy; Newly eligible TAC lay employees; Eligible clergy and lay employees during open enrollment Enrolling in group health benefits
TAC GHB 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
2023 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
Supplemental Counseling Benefit Reimbursement Form Standard PPO Plan participants Reimbursement for out-of-pocket expenses paid for Supplemental Counseling Benefits
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

TAC Wellness Program Forms
Weight Loss Incentive Form All Wellness Program participants Submit for a Weight Loss Incentive request
2023 Annual Maintenance Incentive Form All Wellness Program participants Submit for the Annual Maintenance Incentive request
Pregnancy Weight Loss Incentive Form All Wellness Program participants Submit for a Pregnancy Weight Loss Incentive request

Bariatric Surgery

Requirements and Checklist Package                                      Commitment Form

 Group Health Plan participants Requirements and procedures for bariatric surgery benefit