Trustmark Group Select - Administration Forms

The following administration forms allow plan administrators and employees easy access to claim forms and other coverage change forms necessary to assist with plan administration. Some employee forms may need to be sent to the employer plan administrator before sending to Trustmark Group Select:

Enrollment Forms and Applications
Select your state in order to download the correct employee enrollment form, employer application and/or evidence of insurability form.

Employer Forms for Plan Administration
Automatic Payment Withdrawal Authorization Form
Employee Termination Listing
Group Waiver of Premium/Extended Death Benefit
Proof of Death (Accidental Death)
Proof of Loss of Limb(s) or Sight Statements
Group Long Term Disability Claim Form
Group Short Term Disability Claim Form
Group Conversion Request

Employee Forms for Plan Administration
Medical/Dental Claim Forms
Dependent Student Certification
Request for Change Form
Beneficiary Change Form
Request for Cancellation of Insurance
Coordination of Benefits
Evidence of Insurability
Verification of Dependent Eligibility
Verification of Dependent Eligibility (Incapacitated Dependent)
PHCS Provider Referral Form
Application For Continuation of Coverage
Kansas Application for Continuation of Coverage

HIPAA Privacy Forms
Plan Sponsor Certification to the Group Health Plan
List of Authorized Representatives
Appointment of Personal Representative
Notice of Privacy Practices
Privacy Amendment
Business Associate Agreement