Forms

Domestic Partner

• Domestic Partner Affidavit
• Domestic Partner Dissolution Form

Medical

• Meritain Claim Form
• Meritain Member OIC Form
• HIPAA Authorization Form (Barnes Group)

Pharmacy

• Prescription Drug Claim Form (CVS/caremark)
• Prescription Mail Order Form (CVS/caremark)

HSA

• Common HSA Bank Forms
• Health Savings Account Verification Form
• HSA Rollover Request Form

Dental

• Dental Claim Form (Guardian) 

Vision

• Vision Claim Form (VSP)

Flexible Spending Accounts

• Health Care FSA Claim Form
• Limited Purpose Health Care FSA Claim Form
• Dependent Care FSA Claim Form
• Orthodontia Claim Form
• FSA Medical Necessity (OTC) Form
• FSA Direct Deposit Form

Life Insurance

• Life Insurance Claim Form (Guardian)
• Accidental Death Claim Form (Guardian)
• Accidental Dismemberment Claim Form (Guardian)
• Life Conversion Form (Guardian)
• Life Portability Form (Guardian)

Disability Insurance (Short-Term)

• Short-Term Disability Claim Form (Guardian)
• Short-Term Disability Claim Physician Authorization (Guardian)
• Authorization to Obtain Information (Guardian)

Disability Insurance (Long-Term)

• Long-Term Disability Claim Form (Guardian)
• Long-Term Disability Claim Physician Authorization (Guardian)
• Authorization to Obtain Information (Guardian)

Leave of Absence / Family Medical Leave (FMLA)

• Barnes Group Leave of Absence Request Form
• Connecticut Paid Leave Application Checklist
• Connecticut Paid Leave Employment Verification Form
• Connecticut Paid Leave Statement of Family Relationship
• WH-380-E Certification of Health Care Provider for Employee’s Serious Health Condition
• WH-380-F Certification of Health Care Provider for Family Member’s Serious Health Condition
• WH-384 Certification of Qualifying Exigency For Military Family Leave
• WH-385 Certification for Serious Injury or Illness of Covered Servicemember -- for Military Family Leave
• WH-385-V Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave

Critical Ilness Insurance

• Critical Illness Claim Form (Aetna)
• Critical Illness Wellness/Health Screening Claim Form (Aetna)
• Aetna Voluntary Benefits Portability Form

Accident Insurance

• Accident Insurance Claim Form (Aetna)
• Aetna Voluntary Benefits Portability Form

Hospital Indemnity Insurance

• Hospital Indemnity Claim Form (Aetna)
• Aetna Voluntary Benefits Portability Form

401(K)

• Rollover Form