Member Forms:

• COBRA app
• 401(k) Enrollment
• Customer Relations Appeal Form
• Enrollment Application (other-not education)
• Enrollment Application (education)
• Medical Provider Nomination
• Dental Provider Nomination
• Authorization to Disclose PHI
• Medco COB Form
• FSA Enrollment Application
• FSA Contribution Worksheet
• FSA Reimbursement Form
• Secondary Claim Form
• Medco COB Direct Claim Form (WSU and Washington SD only)
• Vision Claim Form
• Alpine SD (only) Medco Home Delivery Form
• Medco Home Delivery Order Form

Provider Forms:

• TIN Change Form
• TIN Add Form
• Provider Release Form
• Outpatient Notification Form
• Dental Provider Nomination
• Medical Provider Nomination
• Provider Credentialing Application
• Credentialing Application
• Dental Application
• IRS W-9

Employer Forms:

• EMIA Group Application
• EHP Group Application
• FSA Group Application

Broker Forms:

• Group Application
• FSA Group Application

Disability Forms:

Please return all completed forms to the following address:

DISABILITY DEPT
EDUCATORS MUTUAL
852 E ARROWHEAD LN
MURRAY UT 84107-5298
FAX (801)269-9734

• LTD application
• Life Insurance Premium Waiver-Employer
• Life Insurance Premium Waiver-Physicians

Some of the forms may contain different return addresses. Regardless of what the forms say, for efficient processing, they should all be submitted to Educators Mutual. Thank you.