Retirement Benefits Forms

• Church EFT Pension Authorization Form - Authorize payments directly from church bank account for clergy pension contributions.
• UMPIP Contribution Election Form- Completed by the salary-paying unit and submitted directly to Wespath. Specify Before-tax, Roth, and After-tax personal contribution amounts to UMPIP.
• Beneficiary Designation for Retirement and Welfare Plans – Participant - Name a beneficiary to receive retirement benefits in the event of participant's death.

Group Health Benefits (GHB) Forms

Active Clergy / Active TAC Fiscal Office Lay Employees

• TAC Active GHB Enrollment Form- Enrolling in group health benefits for new clergy; newly eligible TAC lay employees; eligible clergy and lay employees during open enrollment.
• TAC GHB Change Form - Make qualified changes outside of the Annual Open Enrollment Period, such as a change of name or address, adding dependent coverage within 31 days of a qualified life event (e.g. birth, adoption, marriage, or loss of other coverage), or termination of dependent coverage.
• Boon-Chapman Medical Claim Form - Reimbursement of out-of-network claims and/or out-of-pocket expenses.
• Supplemental Counseling Benefit Reimbursement Form - Reimbursement for out-of-pocket expenses paid for Supplemental Counseling Benefits.
• EFT - Church Group Health Plan Authorization Form - Authorize payments directly from church bank account for clergy health coverage.
• EFT - Medical Leave Group Health Authorization - Authorizes payments from your bank account for your Group Health contributions.
• Adoption Reimbursement Form - Expenses incurred in the adoption of a child.
• Hearing Aid Benefit Reimbursement Form - Reimbursement of eligible hearing aid expenses.

Under 65 

• U65 GHB Enrollment Form - Enrolling in group health benefits for Under 65 (U65) Early Retirees / Under 65 (U65) Spouses of Medicare Primary Participants / Under 65 (U65) Surviving Spouses / Under 65 (U65) Other Dependents of Medicare Primary Participants. 
•  EFT – Retiree/Surviving Spouse Group Health Authorization form - Authorizes payments from your bank account to maintain Group Health coverage.
• Boon-Chapman Medical Claim Form - Reimbursement of out-of-network claims and/or out-of-pocket expenses.
• Supplemental Counseling Benefit Reimbursement Form - Reimbursement for out-of-pocket expenses paid for Supplemental Counseling Benefits.
• Adoption Reimbursement Form - Expenses incurred in the adoption of a child.
• Hearing Aid Benefit Reimbursement Form - Reimbursement of eligible hearing aid expenses.

Bariatric Surgery

• Requirements and Checklist Package - Requirements and procedures for bariatric surgery benefit.
• Commitment Form - Commitment Form for bariatric surgery.

TAC Wellness Program Forms

• 2023 Annual Maintenance Incentive Form- Submit for the Annual Maintenance Incentive request.
• Weight Loss Incentive Form - Submit for a Weight Loss Incentive request.
• Pregnancy Weight Loss Incentive Form - Submit for a Pregnancy Weight Loss Incentive request.