HealthChoice and OMES Printed Material Request Visit Visit the Office of Management and Enterprise Services (OMES)’s homepage

Enter the quantity amounts to the left of each form requested below. Once you have completed your order click on the 'Submit Order' button. You will receive a copy of the email with details about your order.

Choose your Coordinator type:
Available Forms
Accidental Dismemberment or Loss of Sight Claim Form Employee Benefit Options Book
Application for Coverage for Other Dependent Children Enrollment Form with Guidelines and Privacy Notice
Application for Life Premium Waiver Life Insurance Application
Assessment for Disabled Dependent Life Insurance Application Brochure
Authorization to Disclose Health Information Life Insurance Claim Form
Beneficiary Designation Form Member Audit Form
Change Form with Guidelines and Privacy Notice Premium Refund Request
Change of Address Retiree_Vested_NonVest_Defer Insurance Application
COBRA Enroll Form - EDLG Revocation of Authorization to Disclose Health Information
COBRA – Eligibility for Continuation of Coverage Spouse Exclusion Form
COBRA General Notice of COBRA Continuance of Coverage Rights Supply Order Form for Education & Local Government Insurance Coordinator
COBRA Qualifying Event Notice Termination Form
COBRA – Important Information about your COBRA Continuation Coverage Rights USERRA Life Retention Form
Common Law Spouse Form  
Handbooks Limit of 5 Health Disability Dental Life
Coordinator Information
Coordinator Name:
Entity Name:
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