-A A A+



Benefits Forms

Renaissance Tower - 1201 Elm Street, 23rd Floor, Suite 2300-B, Dallas, TX 75270
Telephone: (214) 653-7638 • Fax: (214) 653-7608


Benefits Forms
Click on the icon to download the form(s) to your computer.
Benefits Enrollment Application for PY2019 - Changes Onlyacrobat
Certification of Other Comparable Coverage - MEDICAL OPT OUTacrobat
Evidence of Insurability **acrobat
Grandchild Affidavitacrobat
Life Beneficiary Formacrobat
Life Insurance Conversion Formacrobat
Long Term Disability Formacrobat
Optional Life Insurance Application - PEBC **acrobat
Portablility Application - PEBCacrobat
Spouse Medical Plan Surcharge Affidavit

To be completed if you are enrolling your spouse in your employer medical plan (PPO Plan or HDP, including retiree PMD/PSD). If you are NOT enrolling your spouse in your employer medical plan you do not need to complete the electronic submission. If you fail to complete the electronic submission or are late submitting it and you enroll your spouse in your employer medical plan, a $200.00 per month surcharge will be assessed every month until the electronic submission is completed. NO REFUNDS!

Click here for instructions on submitting a Spouse Medical Plan Surcharge Affidavit

** During Open Enrollment Optional Life Insurance and Evidence of Insurability are required if you are seeking additional coverage.  Forms will need to be mailed to Dearborn National and postdated no later than November 30. **