Forms – Ensign Benefits

FormsEBAdmin2023-02-14T03:04:05+00:00

Here you’ll find the forms you need to manage your benefits. Download the forms by clicking on the links. You can also request a hard copy of any form by contacting the Benefits Support.

Medical Forms
COVID-19 At-Home Test Direct Reimbursement Claim Form

Dental Forms
Delta Dental PPO Claim Form
Cigna Dental PPO Claim Form

Life, Disability & Voluntary Benefit Forms
Unum Long Term Disability EOI Form
Unum Long Term Disability EOI Form Spanish
Unum STD Claim Form
Unum LTD Claim Form
Unum Supplemental Life EOI Form (001 Dept Heads, Service Center Employees)
Unum Supplemental Life EOI Form (002 Nurses, Therapists)
Unum Supplemental Life EOI Form (003 All Other Eligible Employees)
Voluntary Benefits Claim Form (Critical Illness, Accident Hospital Indemnity)

Other Forms
Emergency Fund Voluntary Donation Authorization
Leave of Absence Request Form