VLCT Group Services has made a number of its important forms available online. Our most frequently used forms can be filled out and submitted online; others are available for printing.
How Can We Help You?
Request More Information About Insurance and Risk Services
Complete and submit online.
Quotation Request
Request a Quote Online
Complete and submit online for group life, short- and long-term disability, and long-term care.
Health
Member Information and Education Request FormDownload, print and complete.CIGNA Enrollment/Change Form
Download, complete and mail or fax to address or number at bottom of form.CIGNA Medical Claim Form
Download and complete.CIGNA Prescription Claim Form
Download and complete.CIGNA Affidavit of Domestic Partnership
Download, print and complete.Age 19 Monthly Dependent Verification Form
Download, print and complete.Annual Student Certification Form
Download, print and complete.
Dental
Northeast Delta Dental Enrollment/Change Form
Download, print and complete.
Northeast Delta Dental Termination FormDownload, print and complete.
Vision
Vision Service Plan Enrollment FormDownload, print and complete.
VLCT PACIF
General Coverage QuestionsComplete and submit online.Certificate of Insurance Request
Complete and submit online.
Workers’ Compensation
First Report of Injury Form
Complete and submit online.
Download, print and complete.
Property
Report Property Listing Change.
Complete and submit online.
Download, print and complete.
Automobile
Vehicle Insurance Card Request
Complete and submit online.
Download, print and complete.
Liability
Liability Accident ReportDownload, print and complete.Liability Hold Harmless Agreement
Download, print and complete.
Unemployment
2009 UI Wage Report (Excel spreadsheet)
Download, complete and return to VLCT via email, fax or U.S. mail.
2009 UI Wage ReportDownload, print and complete.
