Forms & Documents

Complete this form if someone covered by your plan has suffered an injury that was, or may have been, caused by another person.

A document containing information about your COBRA continuation coverage rights.

Complete this form to request an alternate payee for the benefits you receive.

Use this form to notify TeamCare if any other insurance coverage exists for an adult child.

This document contains a list of medicines by drug class that have been removed from your plan’s formulary, or the list of prescriptions that are covered by your plan.

Use this form to order new prescriptions, or order refills, through the CVS caremark™ Mail Order Pharmacy.

Bring this form with you to the pharmacy each time prescription drugs are purchased. Submit this form when you have either $75 in charges or a minimum of 10 prescriptions for you and your dependents.

A list of national pharmacy chains that are a part of the CVS Caremark TeamCare Rx Retail Program.

Use this form to notify TeamCare of a short-term disability due to a non-work-related injury or illness or inability to work due to pregnancy.

Complete this form to notify TeamCare of a continued period of disability.

Use this form to apply for an extension of health coverage for your disabling condition. 

Complete this form to postpone Retiree Health Plan coverage to a later date, if you have other insurance coverage in effect.

Complete this form to reinstate your Retiree Health Plan benefits if you have previously postponed coverage.

Use this form to request Retiree Health Plan coverage for your new spouse.

Use this document to help determine if you are eligible for the Retiree Health Plan.

This form should be completed by a surviving beneficiary or executor of a member’s estate upon their death in order to designate a life insurance beneficiary.

Complete this form in the event of accidental dismemberment from a bodily injury.

Use this form to apply for death and accidental death benefits.

Complete this form to choose a beneficiary for your TeamCare Life Insurance Benefit.

Use this form to apply for total and permanent disability/waiver of premium benefits.

Complete this form to authorize the use and disclosure of your or another member’s protected health information.

This notice describes how medical information about you may be used and disclosed, and how you can access this information.

Complete this form to restrict the use and disclosure of your or another member’s protected health information.

Use this form to request a copy of your or another member’s health and welfare information.

Use these links to access the Summary Annual Reports for active and retiree plans.

Use these links to access the Summary Annual Reports for active and retiree plans.