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
Personal Accident Insurance -- enrollment and beneficiary forms
LegalRx Plan -- enrollment form
Term Life Insurance -- enrollment and beneficiary forms
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.
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