Deseret Mutual Forms Library

The following forms are available in Adobe Acrobat PDF format. If you need Acrobat Reader, you can download it from Adobe's Web site.

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General Enrollment Forms

• Privacy Authorization Form
  
  
• Declaration of Insurability Form
  
  
• Employee Benefit Program Enrollment or Change Form
  
  
• COBRA Medical/Dental Insurance Application please also see the
  The American Recovery and Reinvestment Act of 2009 notice
  
  
• Retiree Medical Coverage Enrollment
  
  
• Retiree Dental Coverage Enrollment
  
  
• Survivor Benefit Enrollment
  
  
• Long Term Disability Benefit Direct Deposit Authorization
  
  
• HMO Enrollment Forms
  
  

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Medical and Dental Forms

• Medical Claim Form
  
  
• Dental Claim Form
  
  
• Prescription Claim Form (this is for Coordination of Benefits and not for FSA claims submissions)
  
  
• Medco New Prescription Mail Order Form
  
  
• Deeming Letter for Deseret Secure Members
  
  
• Healthcare Provider Nomination Form
  
  

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Flexible Spending Account (FSA)

• Flexible Spending Account Medical/Dental Claim Form
  (can be filled out online before printing)

• Flexible Spending Account Dependent Care Claim Form
  (can be filled out online before printing)

• Flexible Spending Account Enrollment Form

• Flexible Spending Account Direct Deposit Authorization

• Flexible Spending Account Change in Family Status Form

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Life Insurance Forms

• Supplemental Group Term Life Insurance Application

• 24-Hour Accidental Death & Dismemberment Insurance Application

• Basic and Supplemental Life Insurance Beneficiary Designation for Active and Disabled Employees

• Retiree Supplemental Group Term Life Insurance Application

• Basic and Supplemental Life Insurance Beneficiary Designation for Retirees and Surviving Dependents

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Financial Benefits

Thrift Plan

• Automatic Contribution Agreement Notice / Annual Safe Harbor Notice
  
  
• Thrift Plan Forms Library
  

Master Retirement Plan

• Direct Deposit Authorization
  
• Release of Information - Participant
  
• Release of Information - Employer
  
• Master Retirement Beneficiary Designation
  
• State Tax Withholding Form
  
• 2009 W-4P Form
  

Retirement Plus Plan

• Retirement Plus Plan Summary Plan Description (SPD)
  

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International Forms

• Prescription Claim Form
  
  
• International Medical Claim Form