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Accident Insurance Program Enrollment Form

To be completed by the worker and employer representative to enroll or change participation in the Accident Insurance Program (AIP).

Annual Open Enrollment Form

To be completed by a worker during an annual open enrollment period who desires enrollment in the Concordia Health Plan for him/herself, a spouse, or dependent children.

The Annual Open Enrollment period for coverage effective 1/1/07 is now closed. Information regarding Open Enrollment for coverage effective 1/1/08 will be sent in special mailings in the fall of 2007.

Application for Catch-up

To be used by a qualifying worker for CRSP contributions above the yearly maximum amount allowable. This form should be turned in to the payroll department or congregational treasurer.

Authorization Form and Instructions – Health Insurance Portability & Accountability Act (HIPAA)

Authorization form for use or disclosure of protected health information. See HIPAA Compliance.

Beneficiary Designation Form - CDSP/AIP

To be completed by the member to report a beneficiary for the death benefits payable from the Concordia Disability and Survivor Plan and/or All-Cause Accident Insurance Program.
NOTE: THIS FORM IS NOT APPLICABLE FOR RETIRED MEMBERS.

Beneficiary Designation Form - CRP

To be completed by the retired member or surviving spouse of a retired member to report a beneficiary for the death benefits payable from the Concordia Retirement Plan. This form can also be completed by a vested terminated worker that has deferred his/her Supplemental Retirement Account (SRA) payment from the Concordia Retirement Plan.
NOTE: THIS FORM IS NOT APPLICABLE FOR ACTIVE WORKERS.

Blue Cross Blue Shield Medical Claim Form

CIGNA Dental Claim Form

CIGNA Dentist Nomination Form

To be completed by the employer to elect which definition of "full-time" to apply to its workers in order to determine Concordia Health Plan (CHP) eligibility.

Electronic Funds Transfer (EFT)

To be completed by the member (or surviving spouse) to set up electronic direct deposit of monthly retirement, disability, and survivor benefits.

Enrollment Form

Express Scripts Formulary

Express Scripts Short-Term Prescription Claim Form

Joinder Agreement

Probationary Period Certification Form

To be completed by an employer wanting to establish a probationary period for delayed enrollment of new employees in the Concordia Plans.

Reason for Non-Enrollment in the Concordia Health Plan

To be completed by a worker when declining enrollment in the Concordia Health Plan for him/herself, the spouse, or dependent children.

Record of Ineligible Worker

To be completed by part-time workers and temporary workers who are not eligible to participate in the Concordia Plans. Select form for Concordia Health Plan (CHP) and/or Concordia Retirement & Disability and Survivor Plan (CRP/CDSP).

Request for Membership Change

To be completed by the member and employer representative to report changes which affect Plans' membership, such as marriage, divorce, new dependent (spouse or child), removal of dependent, change in retirement plan class, and enrollment or change in Accident Insurance Program.

Salary Deferral Agreement

To be completed to indicate amount to be withheld from the worker's salary for contribution to the Concordia Retirement Savings Plan (new tax-sheltered annuity program effective 1/1/06, go to the "Benefits" tab for more details).

Special Enrollment Form

To be completed by a worker who previously declined CHP coverage for him/herself and/or eligible dependents. Special enrollment eligibility requirements will apply.

To be completed by an employer representative or worker to report changes in a worker's Plan membership.

• Worker Change Report – Duties/Hours/Salary: Use this form to report a change in a worker’s duties or hours worked that will result in a salary change or a change in the worker’s eligibility to participate in the Concordia Health Plan (CHP).
• Worker Change Report – New Workers: Use this form to report new workers only. If a new worker is transferring from another LCMS employer, please use the Worker Change Report – Transfers.
• Worker Change Report – Transfers: Use this form to report a worker transferring from one LCMS employer to another LCMS employer.
• Worker Change Report – Termination: Use this form to report a worker termination.