ENROLLMENT FORMS - DEPENDENT CHILDREN HEALTH BENEFIT PLAN
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Dependent Children Health Benefit Plan (DHBP) forms:
NOTE:  Employees of FBI, USSS, DEA, ATF, CBP, CIS, and ICE must complete the SAMBA Payroll Allotment Form 299.  All other agencies must complete the Direct Debit application.
Form Description PDF Type Premium

ENROLLMENT FORMS
DHBP Enrollment Form
DHBP Dental Enrollment
Allotment Form 299
Direct Debit Application Form

HEALTH PLAN CLAIM FORMS
Health Claim Form (CIGNA)
SAMBA Dental Claim Form

SUPPLEMENTAL DENTAL/VISION PLAN FORMS
Aetna Alternate Dental Claim Form
Vision Claim Form



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