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Benefit Forms

Health Care, Vision, and Dental Plans
Helath Care and Vision Older Couple Understanding Your UnitedHealthcare Explanation of Benefits Statement
Understanding Your UnitedHealthcare Health Statement
UnitedHealthcare Health Claim Form
UnitedHealthcare International Health Claim Form
UnitedHealthcare HIPAA Disclosure Authorization Form
UnitedHealthcare Provider Nomination
Authorization Agreement for Pre-Arranged Payments (ACH Debits) Form
Humana Authorization Agreement for Pre-Arranged Payments (ACH Debits) Form
Davis Vision Reimbursement Claim Form
DeltaCare Dental HMO Enrollment Form 
Delta Dental - How to Find a Dentist

 

Pharmacy Benefits
Prescription Drug Bottle Mail Order Form
Pharmacy Reimbursement Claim Form
IRS-Approved Consumer Choice (CDHP) Maintenance Medications

 

Flexible Spending Accounts / Health Savings Accounts
Flexible Spending Account Flexible Spending Account Health Care Claim Form
Flexible Spending Account Dependent Care Claim Form
Health Savings Account Enrollment Form
Health Savings Account Enrollment Form (Online)
Health Savings Account Payroll Deduction Form

 

Life Insurance
Life Insurance Policy Dearborn National: Evidence of Insurability (Online) Application
Dearborn National: Evidence of Insurability Form (English)
Dearborn National: Beneficiary Form
Dearborn National: Evidence of Insurability Form (Spanish)
Dearborn National: Beneficiary Form (Spanish)
Dearborn National: Plan Summary for the City of San Antonio(English)
Dearborn National: Plan Summary for the City of San Antonio (Spanish)
Dearborn National: Plan Certificate of Coverage (Civilian)

 

Deferred Compensation (457) Plans
Compensation 457 ICMA-RC Beneficiary Form
457 ICMA-RC Employee Information Change Form
457 ICMA-RC Enrollment Form
457 ICMA-RC Amount of Deferral Change Form
457 Nationwide Enrollment Form
457 Nationwide Retirement Solutions Payroll Authorization Card
457 Nationwide Change of Beneficiary Form

 

Texas Municipal Retirement System (TMRS)
Retired Couple TMRS:  Service Retirement Checklist
TMRS:  Address or Name Change Form
TMRS:  Direct Deposit Authorization
TMRS:  Change of Beneficiary for Vested Members
TMRS:  Change of Beneficiary for Non-Vested Members
TMRS:  Restricted Prior Service Credit
TMRS:  Refund Application
TMRS: Partial Lump Sum Distribution
TMRS:  Military Service Credit Purchase
TMRS:  Military Service Credit Time Only