Forms

These forms are available in PDF (Portable Document Format). They are best viewed with the latest (free) version of Adobe Acrobat Reader.

Benefits Plan

Life Event Change (Retirees, Survivors & Inactive Plan Members)

Seminary Student Benefits Plan Membership Application

Ministers Bridge Coverage Enrollment: Covenant Package

Ministers Bridge Coverage Enrollment: Congregational Pastors Package or Transitional Pastor's Participation

Validated Ministry Registration

Address and Contact Information Change Form

Post-Retirement Service Registration

Death, Disability & Life Plans

Death Benefits Claim

Student's Application for Education Benefit

Beneficiary Designation Form

Formulario de designación de beneficiarios (Beneficiary Designation Form)

Supplemental Death Benefits Application

Accidental Dismemberment Claim Form

Physician’s Dismemberment Statement

Electronic funds transfer

Authorization for Direct Deposit

Giving opportunities

Assistance Program Gift and Donation Form

Grant applications

Clergy Wellness Support Application

Solicitud de apoyo al bienestar del clero (Clergy Wellness Support Application)

Emergency Assistance Application

Solicitud de asistencia de emergencia (Emergency Assistance Application)

Employee Vocation Program Application

Solicitud del Programa Vocacional para Empleados (Employee Vocation Program Application)

Income/Housing Supplement Application

Solicitud de suplemento de ingresos/suplemento de vivienda (Income/Housing Supplement Application)

Minister Debt Relief Grant Application

Solicitud de subvención de Alivio de la Deuda de Ministros (Minister Debt Relief Application)

Minister Educational Debt Assistance Application

Solicitud para el Programa de Asistencia para la Deuda Educativa de Ministros (Minister Educational Debt Assistance Application)

Medical Record Attestation Form

Organizing Pastors/Evangelists Grant Enrollment Application

Organizing Pastor/Evangelists Grant Renewal Application

Retiree Medical Grant Application

Solicitud de subvención médica para jubilados (Retiree Medical Grant Application)

Sabbath Sabbatical Support Grant Program Application

Solicitud de apoyo sabático al sabbat (Sabbath Sabbatical Support Grant Program Application)

Transition-to-College Assistance Application

Solicitud de asistencia para la transición a estudios universitarios (Transition-to-College Assistance Application)

HIPAA/privacy

Designation of Personal Representative

Authorization to Release Medical Plan Information

의료 보험 관련 정보의 공개를 위한 허가서 (Authorization to Release Medical Plan Information)

Autorización para Divulgar Información del Plan Médico (Authorization to Release Medical Plan Information)

Authorization for Use or Disclosure of Protected Health Information

보안 대상인 건강 관련 정보의 사용 혹은 공개 허가서 (Authorization for Use or Disclosure of Protected Health Information)

Autorización para Usar o Divulgar Información Protegida de Salud (Authorization for Use or Disclosure of Protected Health Information)

Member or Dependent Authorization to Use and Disclose Personal Employment and Financial Information

Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plans - Request for Accounting of Disclosures

Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plans - Request for Access to PHI

Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plans - Request to Amend PHI

Medical/healthcare

Change of Medical Plan Participation for Mission Personnel

VSP Member Reimbursement

Small Employer Exception (SEE) Package

Healthcare Contributions Only Plan: Salary Reduction Agreement

Medical Continuation Enrollment or Waiver Form

Humana Group Medicare Advantage PPO Enrollment form

Humana Group Medicare Advantage PPO Waiver or Withdrawal form

Evidence of Dependent Disability and Support

Pension Plan

Retirement Pension Application - Former Spouse

The Social Security Leveling Option Agreement

Authorization to Release Pension Information

Tax Withholding Election

Retirement Savings Plan

Retirement Savings Plan of the Presbyterian Church (U.S.A.) (Fidelity Enrollment Form)

Retirement Savings Plan Salary Deferral Agreement

Acuerdo de Salarios Diferidos del Plan de Ahorros para la Jubilación (Retirement Savings Plan Salary Deferral Agreement)

Non-QCCO Discrimination Testing for the RSP

Retirement Savings Plan Employment Change