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.
Dental
Northeast Delta Dental Enrollment/Change Form
Download, print and complete.
Northeast Delta Dental Termination FormDownload, print and complete.
Vision
EyeMed Vision Care Enrollment FormDownload, print and complete.EyeMed Out-of-Network Claim Form
Download, print and complete to be reimbursed for eligible services, eyeglasses, and/or contact lenses bought from a provider not in the EyeMed network.
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
Instructionsfor completing the 2010 Annual UI Trust Wage Report
2010 UI Annual Wage Report for members with 1-25 employees (Excel spreadsheet)
Members with 1-25 employees will please save this Excel file and fill it in electronically. Note: Members with up to nine (9) employees may print this file and fill it in manually.
2010 UI Annual Wage Report for members with 26-70 employees (Excel spreadsheet)
Members with 26-70 employees will please save this Excel file and fill it in electronically.
UI Trust members with more than 70 employees will please contact Kelley Avery to arrange to submit their 2010 wage data in an alternative electronic format.
