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Commonly Used Forms

Select the form you wish to view from the list below.

Forms with a symbol next to them are available for online submission.

Alternatively, you may right-click on any link with a symbol and select "Save Target As..." to save the form.

Employee / Member

CareMark (prescrpition drug coverage provider)

Prescription Drug Mail Order Form

Prescription Drug Standard Claim Form

UMR

UMR Certification of Dependent Status

UMR Certification of Dependent Status

UMR Claim Submission Form

UMR Continuity of Care Form

UMR Other Insurance

UMR Dental Claim Form

UMR Medical Claim Form

UMR Possible Third Party Liability

UMR Vision Claim Form

CNIC

CNIC Certification of Dependent Status
CNIC Certification of Dependent Status
CNIC Dental Claim Form (CNIC)
CNIC Medical Claim Form (CNIC/RMHP)
CNIC Other Insurance
CNIC Other Insurance
CNIC Third Party Liability Letter
CNIC Third Party Liability Letter
CNIC Vision Care Claim Form (CNIC)

Standard Insurance Company

Voluntary Life Conversion Request Form

Voluntary Life Portability Application

VSP

Vision Care Out of Network Reimbursement Form (VSP)

Employer / Payroll / Human Resource

CEBT

CEBT Enrollment / Change Card

CEBT Enrollment / Change Card (Spanish)

Certificate of Group Health Insurance Coverage

General

Certificate of Spouse

COBRA Extended Election Period Notice

COBRA General Notice - Abbreviated Version

COBRA General Notice - Full Version

Group Supply Request

Group Supply Request

Medicaid and the Children's Health Insurance Program (CHIP)

The Standard

Life and AD & D Claim Form

CEBT is administered by Willis of Colorado / 303-773-1373 / 800-332-1168 / Fax: 303-773-1685 / Email
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CEBT - Commonly Used Forms