Document
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What it's for...
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Who it's for...
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Retirement Benefits Forms
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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
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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
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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
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Group Health Plan participants |
Requirements and procedures for bariatric surgery benefit |