FORMS

SAMBA Health Benefit Plan

Medical Claim Forms

Standard Option Dental Claim Forms

Medco Prescription Claim Forms

CIGNA Provider Nomination Form

Privacy Authorization Forms

Dependent Children Health Benefit Plan

Enrollment Forms

Health Plan Medical and Preventive Dental Claim Forms

Dental and Vision Care Plan Claim Forms

Other SAMBA Plans Forms

Dental and Vision Care Plan -- enrollment and claim forms

Disability Income Protection Plan -- enrollment form

Group Term Life Insurance -- enrollment and beneficiary forms

Group Term Life Insurance - Age 70 or Older -- enrollment and beneficiary forms

Dependent Group Term Life Insurance -- enrollment form

Supplemental Group Term Life Insurance -- enrollment and beneficiary forms

Personal Accident Insurance -- enrollment and beneficiary forms

LegalRx Plan -- enrollment form

Payment Forms

Payroll Allotment Form 299
NOTE: Employees of FBI, USSS, DEA, ATF, CBP, CIS, and ICE must complete the SAMBA Payroll Allotment Form 299.

Direct Debit Form
All other agencies must complete the Direct Debit application.

Click on the link above if you need to download a free copy of the program.