Forms

To make it easy for you to access the forms you need, we have placed commonly used service forms on this site for you to access at your convenience.

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Claims Forms

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Medical Claim Form

Dental Claim Form

HPFFA Claim Form

EPSI FSA Medical Reimbursement Claim Form

EPSI Dependent Care Reimbursement Claim Form

Flex 125 Enrollment Form

Flex 125 Change Form

DALTILE/UNILIN Dependent Care Expense Reimbursement Voucher

DALTILE/UNILIN Medical Reimbursement Voucher

MAC HAIK Unreimbursed Health Care Expense Reimbursement Voucher

Vision Care Claim Exam Form

Vision Care Claim Eyewear Form

CLEAT HRA Claim Form

CLEAT Dental Claim Form

CLEAT Vision Care Claim Eyewear Form

CLEAT Vision Care Claim Exam Form

Enrollment Forms

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Application Enrollment for Employee Benefit Plan

Application for Enroll or Change for HPFFA Plan

Application for Enrollment into CLEAT Plan

The above forms must be submitted and approved by your employer

Change Forms

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Change to Employee Benefits Plan

Change to CLEAT Plan

The above forms must be submitted and approved by your employer

Other Forms

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Dal-Tile/Unilin ACH Form

HIPAA Authorization Form

Affirmation of Common Law Marriage

Fulltime Student Verification

Subrogation/Right of Reimbursement

Authorization to Release Health Information Form

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