Forms & Documents

Find common forms and documents. Use the search box above the list to find the form you’re looking for.

Form NumberForm NameLast RevisedDownload
CO-638NOTICE OF DEATH - STATE EMPLOYEE8/2015
CO-744 ActiveActive Employee Health Enrollment/Change Form04/2022
CO-744 RetireeCurrent Retirees: Choice of Health Services After Retirement04/2022
CO-819APPLICATION FOR WAIVER OF GROUP LIFE INSURANCE PREMIUM PAYMENTS12/2019
CO-1048NQNON-QUALIFIED CHILD (FORMER WARD) ENROLLMENT APPLICATION5/2012
CO-1048RQQUALIFIED DEPENDENT (FORMER WARD) ENROLLMENT APPLICATION5/2012
CO-1300OPEB Enrollment Form - Retiree Health Fund12/2019
CO-1300BENROLLMENT FORM RETIREE HEALTH FUND FOR EMPLOYEES FIRST HIRED ON OR AFTER 7/1/201712/2019
CO-1301Application for Refund - Retiree Health Contributions12/2019
CO-1302Repayment of Retiree Health Fund For Prior Service Credit 12/2019
CO-1303Affidavit 12/2019
CO-1304Exemption Application and Waiver12/2019
CO-1305Rehired Employee's Waiver of Right to Restore Prior Service Credit for Retiree Healthcare Eligibility12/2019
CO-1314HEP Enrollment Form9/2015
CO-1315Emergency Room Copayment Waiver Request1/2021
CO-1315Emergency Room Copayment Waiver Request - Partnership Plan1/2021
CO-1317For Doctors: Physician Notification Form1/2016
CO-1318Legal Guardianship Notification and Dependency Verification5/2012
CO-1319CHANGE IN MARITAL STATUS NOTIFICATION AND CONTINUATION OF COVERAGE REQUEST5/2012
CO-1321ANNUAL CERTIFICATION QUALIFIED DEPENDENT12/2019
CO-1323RETIREE HEALTH FUND CONTRIBUTION12/2019
CO-1328RETIREE HEALTH FUND PAYMENT ADJUSTMENT12/2019
CO-1329Application for Refund Incorrectly Coded12/2019
CO-1331Lab and Radiology Coinsurance Waiver Request04/2021
PRxOOPrudentRx Opt Out Form04/2022

Summary of Benefits and Coverage (SBC)

Plan Documents

Dental Patient Charge Schedules

Anthem – Machine Readable File