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Online Forms

Types Form Names
Plan Descriptions
Enrollment & Changes

ONPHA Group Insurance Application
Plan Member Enrollment Form
Salary Change Form
Notice of Change Form
Waiver of Coverage Form
Application to Waive Waiting Period Form
Health Evidence Form
Non-Smoking Declaration
Optional AD&D Application Form
Optional Group Life Insurance Application
ONPHA Request for Quote Form

Life Claims

Proof of Death - Physician's Statement
Proof of Death - Claimant's Statement
Proof of Death - Plan Sponsor's Statement
Application for Living Assistance

AD&D Claims

Accidental Dismemberment Claim Form
Dismemberment – Physician's Statement

Disability Claims

Plan Member Guide & Application for Long Term Disability Benefits
Employer Guide for Long Term Disability Benefits
Attending Physician's Statement for Long Term Disability
Plan Sponsor Statement for Long Term Disability
Short Term Disability – Physician's Statement
Short Term Disability – Plan Member Statement
Short Term Disability – Plan Sponsor Statement
Return to Work Notice for Group Disability Benefits

Health & Dental Claims

Drug Claim Submission Form
Claim Form for Related Health Professional Services
Prosthetic Appliances & Medical Equipment Claim Form
Hospitalization Form
Audio Claim Form
Dental Claim Form
Vision Care Claim Form
GSC General Claim Submission Form
Claim for In Home Support

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