These forms are PDF files. If you don't see the form you need, contact your Payroll/Personnel officer or Trust Customer Service for further assistance. If you do not have Adobe Acrobat installed on your computer, download it here.

Delta Dental Plan

Enrollment and Change form - Use this form to enroll in your dental and vision benefits within 31 days of your one-year anniversary of being hired by the State. When completed, please give the form to your Payroll/Personnel officer. Click here to download the form.

Claim form - You may download this form to take to your dentist in order to file a claim.

Legal Plan

Enrollment Form - Use this form to enroll in the legal service plan, offered by Hyatt. This is also the form to use when changing or dropping your legal plan coverage, which you may only do during open enrollment. You may enroll in this coverage within 90 days of hire or at the next open enrollment.

Vision Plan

Enrollment and Change form - Use this form to enroll in your dental and vision benefits within 31 days of your one-year anniversary of being hired by the State. When completed, please give the form to your Payroll/Personnel officer. Click here to download the form.

No forms are required when you visit in-network vision providers in either plan. For out-of-network claims, VSP requires you to submit itemized receipts in six months of service; EyeMed requests a phone call so that you can obtain a claim form prior to your visit.

Supplemental Life Insurance

Enrollment Form - Use this form to enroll in supplemental life insurance coverage for you and your dependents from the Trust. You can enroll in supplemental life insurance during any Trust open enrollment (next open enrollment will be spring 2008) or within 90 days of your date of hire by the State. When completed, please copy the form for your records, and mail it to Prudential.

Once enrolled, your coverage will remain in force until you leave State service, unless you change your coverage. When you leave, you may convert or port your coverage. To apply for port, simply complete the form that Prudential will mail to you. To apply for conversion, use this form, which may also be used for dependent life insurance and basic life insurance. If you are laid off or on leave, you may continue your supplemental life coverage by using the continuation form. Note that the address for death claim filing has changed to PO Box 8517, Philadelphia, Pennsylvania, 19176-9802; however, this does not affect the processing of supplemental life enrollment, termination, conversion or porting.

Make sure you have a declared beneficiary; a designated beneficiary on file will ensure that your benefits will go directly to those you care about, should you die while covered under basic or supplemental life insurance from the Trust. Contact Prudential now if you aren't sure if you declared or updated your beneficiary. This form can be used for both basic and supplemental life insurance.

For instructions, click here. For the benificiary form, click here.

Working Solutions

This service does not require any forms. You may simply contact them by phone or visit their web site.

Affidavit

Documentation may be required with an affidavit when you first enroll or when the child is first eligible (Eligibility - indicates some of the instances when an affidavit may be required), or annually for dependents over 19. The Trust dental and vision plans have the same affidavit/documentation requirements as the medical plan, and you should be able to use the same affidavit for all your plans. Affidavits are available from your Payroll/Personnel officer. When completed, please return the form to your Payroll/Personnel officer.