DMBA Forms Library

Forms marked with an asterisk are accessible after login to complete and sign online. When opening the form, enter your email address and the same first and last name you will use to sign the form. Forms with mismatched signatures will not be accepted. You may also download these forms as PDFs after login.

General Enrollment Forms

• Employee Benefit Enrollment Form*
• Employee Benefit Enrollment Form for Hawaii
• Retiree Benefit Enrollment Form
• DMBA-affiliated HMO Applications
• Senior Dental Plan Enrollment Form
• Automatic Premium Debit Authorization Agreement
• Disability Direct Deposit Authorization
• Declaration of Insurability
• Authorization to Disclose Retirement or Life and Accident Benefit Information*
• Authorization to Use and/or Disclose Protected Health Information (PHI)*

DMBA Medical, Dental, and Prescription Forms

• Medical and Dental Claim Form*
• International Medical and Dental Claim Form
  (For reimbursement of services received outside the U.S.)
• Navitus Prescription Drug Claim Form
  (Domestic Claim—Direct Member Reimbursement)
• Navitus Prescription Drug Claim Form
  (Foreign Claim—Direct Member Reimbursement)
• Member Appeal Form*
• Member Benefit Suggestion Form
• Provider Nomination Form
• Provider Review Form
• Claim Information Request (for accident, injury, or illness)

COBRA Forms

• COBRA Election Form for 2024
• COBRA Election Form for 2025
• Notice of Qualifying Event
• Notice of Second Qualifying Event
• Notice of Disability
• Notice of Cessation of Disability
• Notice of Other Coverage or Medicare Entitlement

Medicare-related Forms

• Medicare Part B Claim Form

Flexible Spending Account (FSA) Forms

• 2024 Flexible Spending Claim Form for Healthcare Expenses
  (can be filled out online before printing)
• 2024 Flexible Spending Claim Form Dependent Care Expenses
  (can be filled out online before printing)
• Flexible Spending Enrollment
  (can be filled out online before printing)
• Flexible Spending Letter of Medical Necessity
  (can be filled out online before printing)
• Flexible Spending Direct Deposit Authorization

Health Savings Account (HSA) Forms

• Authorization to Disclose Health Savings Account (HSA) Information
• Beneficiary Form (HSA Only)   Review and designate your beneficiaries online right now.

Life Benefit Forms

• Beneficiary Form   Review and designate your beneficiaries online right now.
• Supplemental Group Term Life Application
• 24-Hour Accidental Death & Dismemberment Application
• Retiree Supplemental Group Term Life Application
• Retiree Supplemental Group Term Life Application (hired on or after April 1, 2010)

Financial Benefits Forms

• Beneficiary Form   Review and designate your beneficiaries online right now.
• Authorization to Disclose Retirement or Life and Accident Benefit Information*

Deseret 401(k) Forms

Click here to access Deseret 401(k) Plan forms on Empower Retirement’s website.

• Form W-4P federal withholding form (Savings)

Master Retirement Plan Forms

• A Guide to Your Payment Options
• Information release - participant*
• Information release - employer
• Master Retirement Plan and Savings Annuity Direct Deposit Authorization
• Form W-4P federal withholding form (Retirement)
• Request for State of Utah Income Tax Withholding
• Form A-4 Arizona withholding form
• Form DE-4P California withholding form
• Form ID W-4 Idaho withholding form