Forms

		Health Plan 2010 Open Enrollment TRS-ActiveCare New Employees Plan Descriptions Find a Network Provider Forms Filing a Claim Prescriptions Lab Work Employee Assistance Program Changing Benefits Pre-Existing Condition Limitation Part-Time Benefits COBRA HIPAA Flexible Benefit Program Plan Documents

All Claim Forms and Instructions

2009 Prescription Mail-Order Form (242 KB) & Instructions (14 KB)

Cancel Life Insurance or Disability Insurance (10 KB) - Life insurance may be canceled anytime, but disability insurance may only be canceled during the annual open enrollment period.

Disability Insurance:

• Online Enrollment Request - Refer to printed enrollment materials for login instructions.
• Brochure and Paper Application Form (145 KB)
• 2009 Disability Plan Rates:
  7/7 elimination period (46 KB)
  14/14 elimination period (46 KB)
  30/30 elimination period (46 KB)
  90/90 elimination period   (46 KB)
• 2010 Disability Plan Rates:
  7/7 elimination period (36 KB)
  14/14 elimination period (36 KB)
  30/30 elimination period (36 KB)
  90/90 elimination period (36 KB)

Optional Life Insurance:

• Application Form (153 KB)
• Health Questionnaire (136 KB)
• You must complete both the application form and health questionnaire if you are applying for optional life insurance either 1) after your first 60 days of employment, or 2) if you are a new employee requesting more than $150,000.
• Return completed forms to the Plano ISD Benefits office.

TRS-ActiveCare Forms:

Application to Split Premium (188 KB) - Use this form ONLY if you and your spouse work for different school districts and you qualify to split the family premium. Do not use this form if you and your spouse both work for PISD.

Dependent Child's Statement of Disability (182 KB) - Use this form if you will be requesting TRS-ActiveCare medical coverage for a disabled child over age 25.

Transitional Care Request Form (171 KB) - Use this form if you will be using a non-network doctor under TRS-ActiveCare. The criteria to qualify for transitional care are explained in the TRS Benefits Booklet on page 38.