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Benefits Management Solutions

Members Forms FAQ     Forms Download the appropriate form and follow the instructions.   Authorization To Disclose Protected Health Information In order to process your case, we may need to have you complete an Authorization To Disclose Protected Health Information. Download   Bank Draft Authorization for Non-Group Plans Change how your premium is paid. Download   Common Law Marriage Questionnaire Print and bring this form to your local notary to allow us to recognize your common law marriage. Download   Express Scripts Claim Form Use this form to submit your Rx receipts for reimbursement. Read and follow the instructions carefully. Make sure to include all of the requested information. Download   Full-time Student Verification Form Verify the eligibility of your college-aged (19-24) dependent. Make sure to include any supporting enrollment documentation. Download   Statement of Good Health Our underwriters may request a Statement of Good Health from you while evaluating your submission. Make sure to sign the form before faxing or mailing the form to the number or address specified by your underwriter. Download     Forms for Employers Only:   Change of Business Address Note: Must be completed by business owner only. Download   Delete a Terminated Employee / Add an Employee Newborn or Adopted Dependent Employers must use this form to notify us of terminations and separations of employees and to add any employees’ newborn or adopted dependents. Note: To add other types of dependents, a full employee application will be required. Download         ©2008 Insurers Administrative Corporation      Disclaimer