Important Benefits Forms

Health Insurance Forms

BCBS Enrollment, Change, Waiver Form Eligible Clergy & Laity Enroll in coverage, add a dependent, change address, change name, waive initial coverage
BCBS Drop Dependent Coverage Form Covered Cergy & Laity Drop a dependent from health insurance plan
United Concordia Dental Claim Form United Concordia Claim Instructions Covered Clergy & Laity For expenses incurred with non-network dentist (network dentist file for you)
BCBS Medical/Vision Claim Form
BCBS Prescription Claim Form
Covered Clergy & Laity File a claim with BCBS for medical, vision, and/or prescription expenses
Church Benefits Authorization [EFT] Church Finance Staff Authorize payments directly from church bank account for Benefits bill
GBOPHB Health Plan Deduction [EFT] Retired Clergy
Surviving Spouse
Authorize the General Board of Pension & Health Benefits to deduct the health insurance premium from pension check
LA Conf. Health Plan Deduction [EFT] Retired Clergy
Surviving Spouse
Authorize the LA Annual Conference to deduct the health insurance premium from bank account

Health Savings Account Forms

Additional Deposit Form Church Finance Staff Send clergy payroll withholding for HSA to AHR
Change Form Elgible Clergy & Laity Make changes in address, name, contribution amounts
Claim Form Elgible Clergy & Laity Send in claims to be paid on the account (can also be done on-line)
Elgibility For Contributions Elgible Clergy & Laity Annual verification of eligibility to participate in an HSA
Enrollment Form Elgible Clergy & Laity Clergy or laity covered by the health insurance enrolling for an HSA

Pension Forms

Before/After Tax Contributions Agreement Elgible Clergy & Laity Specify before and after tax UMPIP contribution amounts
Church Benefits Authorization [EFT] Church Finance Staff Authorize payments directly from church bank account for Benefits bill
Designation of Beneficiary for Retirement/Welfare Participant Elgible Clergy & Laity Name a beneficiary to receive retirement and other GBOPHB benefits in the event of participants death
Enrollment Form CRSP, UMPIP, CPP Elgible Clergy Clergy enrolling in CRSP, UMPIP, CPP
Enrollment Form UMPIP Elgible Laity Laity enrolling in UMPIP
Change Form UMPIP Elgible Clergy & Laity Clergy and laity already enrolled in UMPIP who wish to change their UMPIP amounts
Waiver Of Participation [CRSP] Elgible Clergy To waive participation in CRSP by a clergy person serving less than full time
Waiver Of Participation [UMPIP] Elgible Clergy For ¼ time clergy to waive participation in UMPIP after they have previously submitted a Before-Tax and After Tax Personal Contributions agreement

Special Retiree Benefits

Moving Expense Voucher Retiring Clergy Submit claim for moving expenses paid for move when retiring