Member Forms

All the forms you need can be found right here. Simply select the form you want and you'll be able to download and print a ready-to-use version.
Please note: Select only the forms appropriate to the coverage(s) in which you are enrolled.
Enrollment/Change	Your Human Resources Representative	Use this form to enroll or change enrollment status in the plan. All enrollment forms must be submitted to your company's Human Resources department. Once the changes have been approved, they will submit the necessary information to Benesight.
Dental Claim Form	Company PO Box 2900 Anytown, USA 55555- 2900	Use this form to submit any claims that are not filed by your doctor's office. You can use this form for medical, dental or vision claims.
Medical Claim Form	Company PO Box 2900 Anytown, USA 55555- 2900	Use this form to submit any claims that are not filed by your doctor's office. You can use this form for medical, dental or vision claims.
Accident/Injury Details	Company PO Box 2900 Anytown, USA 55555- 2900	Use this form to provide additional information on claims caused by an accident or injury.
Full-time Student Status	Company PO Box 2900 Anytown, USA 55555- 2900	Use this form to provide information about a dependent attending school full-time.
Other Insurance Coverage	Company PO Box 2900 Anytown, USA 55555- 2900 Pueblo CO 81002	Use this form to provide information about other insurance coverage you may have.
Short-Term Disability Notice	Company PO Box 2900 Anytown, USA 55555- 2900	Use this form to submit disability notification.
Flexible Reimbursement	Company PO Box 2900 Anytown, USA 55555- 2900	Use this form to request reimbursement from the member's Flexible Spending Account.
Flexible Benefit Program	Your Human Resources Representative	Use this form to enroll or change enrollment status in a Flexible Benefit Program. All enrollment forms must be submitted to your company's Human Resources department. Once the changes have been approved, they will submit the necessary information to Benesight.
View Additional Forms
Because all forms are stored in PDF format, you'll need Adobe Acrobat Reader® to view or print them. The reader takes just moments to install, and is available for free download. When you have a form open, you can print it by clicking on the printer icon located above the form in the Adobe Acrobat toolbar. Please read all form instructions carefully to ensure we can process your request correctly, quickly and efficiently.
Disclaimer: Benesight may not be the administrator for these coverages or you may not be eligible to participate in these coverages. Please check with your HR Representative if you have any questions about your coverage status.