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Insurance Forms

This document contains many of the forms that Crawford County employees will need for all insurance policies: health, dental, and life.

Blue Cross Blue Shield Forms

New Employee Application: For new employees to fill out.

Change Form: Use this form to add or delete people from your plan. Also use this form to terminate your coverage, if for example you are switching to a different plan offered by a different employer or group.

COBRA Form: This form will be sent to employees who have lost their insurance benefits and wish to continue on the group policy at an expense to the employee.

Claim Form: Use this form if your provider did not send a claim to Blue Cross and Blue Shield of Kansas.

Claim Appeal Form: Use this form to appeal a claim you feel has been inadequately processed.

Mail Order Form: Use this form to order prescriptions by mail.

Affidavit of Marriage: Use this form to provide certification of a common law marriage for coverage of a common law spouse.

Application for Coverage of Handicapped Dependent: Use this form to provide certification of a handicapped dependent who has reached the age limit.

Delta Dental Plan of Kansas Forms

Enrollment/Change Form: For new employees to fill out. Use this form to add or delete people from your plan. Also use this form to terminate your coverage, if for example you are switching to a different plan offered by a different employer or group.

Claim Form: Use this form if your provider did not send a claim to Delta Dental Plan of Kansas.

Advance Life Insurance Company of Kansas Forms

Enrollment/Change Form: For new employees to fill out. Use this form to add, delete, or change your beneficiary. Also use this form to terminate your coverage, if for example you are switching to a different plan offered by a different employer or group.

Conversion Application: This form will be sent to employees who have lost their insurance benefits and wish to continue on the group policy at an expense to the employee.

Death Claim Form: Use this form to certify death to receive death benefits provided by Advance Life Insurance.

Disability Claim Form: Use this form to start the process for disability claims.

Affidavit of Common Law Marriage: Use this form to provide certification of a common law marriage for beneficiary purposes.