Our forms are grouped categorically for ease of reference, and the purpose of each form is described in brief sentence next to the downloadable pdf.


 BenefitMall Forms

BenefitMall Election Form
This form allows you to enroll in the benefits program.

BenefitMall Change Form
This form allows you to add/change/cancel coverage. It also allows you to change your address or the spelling of your name within the plan.

Kelly Insurance Services

Kelly Election Form
This form allows you to enroll in the benefits program.

Kelly Change Form
This form allows you to add/change/cancel coverage. It also allows you to change your address or the spelling of your name within the plan.

Aetna Forms

Aetna Election/Change Form
This form allows you to enroll in the benefits program. You would also use this form to add/change/cancel your coverage. It also allows you to change your address or the spelling of your name.

Release Authorization Form
This form give Aetna permission to release protected health information to a third party on your behalf.

CareFirst Forms

Release Authorization Form
This form give CareFirst permission to release protected health information to a third party on your behalf.

DHMO  Application for Individual Dental

DHMO Rate Sheet for Individual Dental

DHMO Brochure for Individual Dental

Preferred Application for Individual Dental

Preferred Rate Sheet for Individual Dental

Preferred Brochure for Individual Dental

Coventry Forms

Release Authorization Form
This form give Coventry permission to release protected health information to a third party on your behalf.

MHIP Forms

MHIP Brochure
This form explains the the benefits and application process for MHIP

MHIP Application
This is the application to enroll in MHIP

MHIP Rates
This form lists the rates for MHIP effective July 1, 2009

MHIP + Application
This is the application for MHIP at reduced premiums based on income

HSA Informational Documents

HSA: Defined and Outlined
This form describes what an HSA is and how it can be used

CareFirst on HSA's
This form provides a comprehensive explanation of how CareFirst  HSA plans work.

HSA Eligible Expenses
This form lists all medical expenses that can be paid for from an HSA Account

MRSPA Forms

Change Request for MRSPA
This form allows you to add/change/cancel converage. It also allows you to change your address or spelling of your name. Completed form must be returned to BenefitMall for Process. Please note their address on the form.

Dental MRSPA Concordia (DHMO)
Premium Rates for 11/1/2009-10/31/2010 and Benefit Description for the United Concordia DHMO plan.

Dental MRSPA Concordia (Your Choice)
Premium Rates for 11/1/2009-10/31/2010 and Benefit Description for the United Concordia POS plan.

Dental MRSPA Carefirst Info
Premium rates for 11/1/2009-10/31/2010 and Benefit Description for both of the CareFirst dental plans.

Enrollment for MRSPA
This form allows you to enroll in the benefits. Completed form must be resturned to BenefitMall for processing. Please note their address on the form.

Vision Summary MRSPA Spectera Comp
Premium Rates for 11/1/2009-10/31/2010 and Benefit Description for the Spectara Vision insurance plan.

Vision Summar MRSPA Spectera Disc
Premium Rates for 11/1/2009-10/31/2010 and Benefit Description for the Spectra Vision Discount Plan.

Medigap Forms

Medigap Coverage Outline                                                                                                                                            This form outlines Medigap services and coverage.

Medigap Brochure                                                                                                                                                            This form explains the the benefits and application process for Medigap.

Medigap Application                                                                                                                                                      This is the application to enroll in Medigap.

Short Term Medical Coverage

Golden Rule Application

Download PDF reader here.