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 (E-11)
  
  
• Employee Benefit Program Enrollment or Change Form (E-03A&B)
  

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Medical and Dental Forms

• Medical Claim Form (M-01)
  
  
• Dental Claim Form (D-01)
  
  
• Prescription Claim Form (E-67)
  (this is for Coordination of Benefits and not for FSA claims submissions)



• Medco New Prescription Mail Order Form
  
  
• Deeming Letter for Deseret Secure Members

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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 (F-03)

• Flexible Spending Account Direct Deposit Authorization (F-09)

• Flexible Spending Account Change in Family Status Form (F-04)

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Life Insurance Forms

• Supplemental Group Term Life Insurance Application (E-43)

• 24-Hour Accidental Death & Dismemberment Insurance Application (E-08)

• Basic and Supplemental Life Insurance Beneficiary Designation for Active and Disabled Employees (E-22A)

• Basic and Supplemental Life Insurance Beneficiary Designation for Retirees and Surviving Dependents (E-22B)

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Thrift Plan

• Automatic Contribution Agreement Notice / Annual Safe Harbor Notice

• Thrift Plan Forms Library

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Master Retirement Plan

• Master Retirement Beneficiary Designation (R-06)

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International Forms

• Prescription Claim Form (E-67)
  
  
• International Medical Claim form (M-04)
  
  
• International Exchange Rate Notification form (I-02)

 

 

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