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DMBA Forms Library

Forms marked with an asterisk are accessible after login to complete and sign online. When opening the form, enter your email address and the same first and last name you will use to sign the form. Forms with mismatched signatures will not be accepted. You may also download these forms as PDFs after login.

General Enrollment Forms

Employee Benefit Enrollment Form
Employee Benefit Enrollment Form for Hawaii
Retiree Benefit Enrollment Form
DMBA-affiliated HMO Applications
Senior Dental Plan Enrollment Form
Automatic Premium Debit Authorization Agreement
Disability Direct Deposit Authorization
Declaration of Insurability
Authorization to Disclose Retirement or Life and Accident Benefit Information*
Authorization to Use and/or Disclose Protected Health Information (PHI)*

DMBA Medical, Dental, and Prescription Forms

Medical and Dental Claim Form
International Medical and Dental Claim Form
(For reimbursement of services received outside the U.S.)
Navitus Prescription Drug Claim Form
(Domestic Claim—Direct Member Reimbursement)
Navitus Prescription Drug Claim Form
(Foreign Claim—Direct Member Reimbursement)
Member Appeal Form
Member Benefit Suggestion Form
Provider Nomination Form
Provider Review Form
Claim Information Request
(For accident, injury, or illness)

COBRA Forms

COBRA Election Form
Notice of Qualifying Event
Notice of Second Qualifying Event
Notice of Disability
Notice of Cessation of Disability
Notice of Other Coverage or Medicare Entitlement

Medicare-related Forms

Medicare Part B Claim Form

Flexible Spending Account (FSA) Forms

Flexible Spending Claim Form for Healthcare Expenses for FSA and LPFSA
(Can be filled out online before printing)
Flexible Spending Claim Form Dependent Care Expenses
(Can be filled out online before printing)
Flexible Spending Enrollment
(Can be filled out online before printing)
Flexible Spending Letter of Medical Necessity
(Can be filled out online before printing)
Flexible Spending Direct Deposit Authorization

Health Savings Account (HSA) Forms

Authorization to Disclose Health Savings Account (HSA) Information
Beneficiary Form (HSA Only)
Or click here to review and designate your beneficiaries right now

Life Benefit Forms

Beneficiary Form
Or click here to review and designate your beneficiaries right now
Supplemental Group Term Life Application
24-Hour Accidental Death & Dismemberment Application
Retiree Supplemental Group Term Life Application
(Hired before April 1, 2010)
Retiree Supplemental Group Term Life Application
(Hired on or after April 1, 2010)

Financial Benefits Forms

Beneficiary Form
Or click here to review and designate your beneficiaries right now
Authorization to Disclose Retirement or Life and Accident Benefit Information*

Deseret 401(k) Forms

Click here to access Deseret 401(k) Plan forms on Empower Retirement’s website
Form W-4P federal withholding form (Savings)

Master Retirement Plan Forms

A Guide to Your Payment Options
Information release — participant*
Information release — employer
Master Retirement Plan and Savings Annuity Direct Deposit Authorization
Form W-4P federal withholding form (Retirement)
Request for State of Utah Income Tax Withholding
Form A-4 Arizona withholding form
Form DE-4P California withholding form
Form ID W-4 Idaho withholding form