Forms

We have made copies of forms available for you to print from your computer. Click the links below to access the forms in portable document format (PDF). (You need Adobe Acrobat on your computer to read a PDF format. If you do not have the latest version of Adobe Acrobat, you can download it for free.  Keep in mind that some forms may take a few minutes to download.)

If you don't see the form you need here, or you have questions about which form to use, call the Trust office at (239) 936-6242.

NEW! To enroll an eligible spouse for Trust benefits...

Spouse enrollment form

Select the link above to learn more about enrolling an eligible spouse for coverage.

To enroll in the PPO...

There are several PPO enrollment forms. Use the form that applies to you based on your location. 

For participants in Waco, Texas, and Ohio
UnitedHealthcare PPO Enrollment Form

For participants in Pennsylvania, Illinois, and Central New York
Highmark Blue Cross Blue Shield PPO Enrollment Form

For participants in Indiana
MultiPlan (formerly ProAmerica/BCE Emergis)

For participants in all other locations
MultiPlan (formerly ProAmerica/BCE Emergis)

To submit your first medical claim form of the year for the Trust indemnity program (please do not submit one every time you file a claim)

Notice of Claim for Trust indemnity program (2 pages)

To change your life insurance beneficiary

Life Insurance Change of Beneficiary

To change your address or marital status

Change of Address or Marital Status

Important: You must notify the Trust office immediately when you and/or your spouse become eligible for Medicare for any reason other than attaining age 65. Write or call the Trust at:

G.M.P. - Employers Retiree Trust
5245 Big Pine Way, S.E.
Fort Myers, FL 33907-5998
Phone: (239) 936 6242

 

Copyright 2006, G.M.P. - Employers Retiree Trust, All Rights Reserved