Forms

Below are a variety of forms you might need to make a claim on your plan, make changes to your beneficiaries, and more. If you do not see the type of form you need, it may be available through your school jurisdiction. Please contact them, your employee representative or ASEBP if you have any questions.

Please select from the list below which form you would like. All forms require Adobe Acrobat Reader to be viewed.

Claim Forms
	Dental Care Claim Form
	Extended Health Care/Vision Care
	Emergency Out of Country Claim
	Health Spending Account Expense Reimbursement

Application Forms
	Change Application for Substitute Teachers and Casual Staff
	Group Insurance Change Application

Banking Forms
	Direct Withdrawal of Premium Payments
	Automatic Direct Deposit

Administrative Forms
	Additional Health Benefit Information
	Appointment of Beneficiary(ies) – Life and Accidental Death & Dismemberment
	Consent (ASEBP 130 & 103A)
	Declaration of Eligibility to Participate in Benefits for Substitute Teachers and Casual Staff
	Early Refill letter
	Medical Evidence of Good Health – Substitute Teachers and Casual Staff
	Over-Age Dependent Notification