Deseret Mutual Forms Library

The following forms are available in Adobe Acrobat PDF format. If you need Acrobat Reader, you can download it from Adobe's Web site.

General Enrollment Forms

• Privacy Authorization Form
• Declaration of Insurability Form
• Employee Benefit Program Enrollment or Change Form
• Long Term Disability Benefit Direct Deposit Authorization

Medical and Dental Forms

• Medical Claim Form
• Dental Claim Form
• Prescription Claim Form (this is for Coordination of Benefits and not for FSA claims submissions)
• Medco New Prescription Mail Order Form
• Deeming Letter for Deseret Secure Members
• Healthcare Provider Nomination Form
• COBRA Medical/Dental Insurance Application please also see the
  The American Recovery and Reinvestment Act of 2009 notice
• Retiree Medical Coverage Enrollment
• Retiree Dental Coverage Enrollment
• Survivor Benefit Enrollment
• HMO Enrollment Forms

Flexible Spending Account (FSA)

• Flexible Spending Account Medical/Dental Claim Form
  (can be filled out online before printing)
• Flexible Spending Account Dependent Care Claim Form
  (can be filled out online before printing)
• Flexible Spending Account Enrollment Form
• Flexible Spending Account Direct Deposit Authorization
• Flexible Spending Account Change in Family Status Form

Life Insurance Forms

• Supplemental Group Term Life Insurance Application
• 24-Hour Accidental Death & Dismemberment Insurance Application
• Basic and Supplemental Life Insurance Beneficiary Designation for Active and Disabled Employees
• Retiree Supplemental Group Term Life Insurance Application
• Basic and Supplemental Life Insurance Beneficiary Designation for Retirees and Surviving Dependents

Financial Benefits

Thrift Plan

• Automatic Contribution Agreement Notice / Annual Safe Harbor Notice
• Thrift Plan Make-up Calculation Request
• Make-up contributions
• Loan Payment Form
• Consent Form to Access My Account
• Annual Safe Harbor Notice
• Terminated/Retired Employee with Outstanding Loan
  • For Loans Started Prior to December 1, 2004
  • For Loans Started December 1, 2004 and Later

Master Retirement Plan

• Direct Deposit Authorization
• Release of Information - Participant
• Release of Information - Employer
• Master Retirement Beneficiary Designation
• State Tax Withholding Form
• 2009 W-4P Form

Retirement Plus Plan

• Retirement Plus Plan Summary Plan Description (SPD)

International Forms

• Prescription Claim Form
• International Medical Claim Form