Claim Reporting and Insurance Forms

This page contains links to useful forms for VLCT's three self-insurance trusts. The pencil icon shows the forms that can be filled in and submitted completely online. The PDFs are for you to fill in on paper and submit by standard mail, fax, or scan & email as indicated on each form.

VLCT PACIF

• General Coverage Questions
• Certificate of Insurance Request

Workers’ Compensation

• First Report of Injury Form
• Non-Employee Work Agreement

Property

• Report Property Listing Change
  Complete and submit online.
• Property Loss Report
  Download, print and complete.

Automobile

• Vehicle Insurance Card Request
  Complete and submit online.
• Vehicle Accident Report
  Download, print and complete.

Liability

• Liability Accident Report
  Download, print and complete.
• Liability Hold Harmless Agreement
  Download, print and complete.

Unemployment Insurance (UI) Trust

• 2012 UI Trust Annual Wage Report Form (Excel spreadsheet)
  Download, complete and return to VLCT via email, fax or U.S. mail.
• 3/1/2013 Memo to Members RE: 2012 UI Trust Annual Wage Report (PDF)
  Letter explaining how UI Trust members should report their 2012 wage data to VLCT.

 

Health Trust 

Please note: The files posted here are intended for use by current VLCT Health Trust members and their covered employees during a current plan year. Employer groups not currently in the Health Trust or current Health Trust members that intend to switch carriers for the upcoming plan year will please click here to be redirected to the appropriate enrollment kits.

BlueCross BlueShield of Vermont (BCBSVT) — Direct or via AIV

• BCBSVT Individual Enrollment/Change Form
  Complete and submit directly to BCBSVT.
• BCBSVT Waiver of Group Health Insurance Benefits Form
  Complete and submit directly to BCBSVT.
• BCBSVT Statement of Domestic Partnership
  Complete and submit directly to BCBSVT.
• BCBSVT Out-of-Network Medical Claim form
  Includes instructions for subscriber to complete form, attach relevant receipts, and submit all to BCBSVT.
• BCBSVT-Express Scripts Prescription Drug Claim Form
  Includes instructions for subscriber to complete form, attach relevant receipts, and submit to Express Scripts.

BlueCross BlueShield of Vermont (BCBSVT) — via VACE

• BCBSVT-VACE Individual Enrollment/Change Form
  Complete and submit to VACE.
• BCBSVT Out-of-Network Medical Claim form
  Includes instructions for subscriber to complete form, attach relevant receipts, and submit all to VACE.
• BCBSVT-Express Scripts Prescription Drug Claim Form
  Includes instructions for subscriber to complete, attach relevant receipts, and submit to Express Scripts.

Cigna

• Cigna Individual Enrollment/Change Form
  Complete and submit to Cigna.
• Cigna Affidavit of Domestic Partnership
  Complete in the presence of a Notary and submit to Cigna.
• Cigna Member (Individual) Medical Claim Form
  Includes instructions for subscriber to complete, attach relevant receipts, and submit directly to Cigna.
• Cigna Prescription Drug Claim Form
  Includes instructions for subscriber to complete, attach relevant receipts, and submit directly to Cigna.

MVP of Vermont

• MVP Recertification Form for Small Group Renewals
  Complete, sign, and submit to the attention of Heather Blackman, MVP Health Care, 66 Knight Lane Suite 10, Williston, VT 05495. You must also include a copy of your most recently completed C-101 (Employer's Quarterly Wage & Contribution Report) with this form.
• MVP Individual Enrollment/Change Form
  Complete and submit to MVP's Vermont office.
• MVP Waiver of Coverage Confirmation Form
  Employees not obtaining coverage through the municipality must complete this form and submit it to MVP's Vermont office.
• MVP Affidavit of Domestic Partnership
  Employees wishing to cover a domestic partner must complete this form and submit it to MVP's Vermont office.
• MVP Medical Claim Form
  Includes instructions for subscriber to complete form, attach relevant receipts, and submit all to MVP's Vermont office.
• MVP-Medco Prescription Claim Form
  Complete and submit to Medco, MVP's partner for prescription coverage.

Dental

• Northeast Delta Dental Enrollment/Change Form
  For employees of groups that cover dependents ages 19-25 if they are full-time students.
• Northeast Delta Dental Enrollment/Change Form
  For employees of groups that have opted in to cover all dependents ages 19-25.
• VLCT Dental Employee Termination Form
  For administrators from all groups to use to terminate coverage for one or more employees. Coverage for terminated employees' spouses and dependents will automatically be discontinued as well.

Vision

• EyeMed Vision Care Individual Enrollment/Change Form
  Download, print and complete.

Didn't Find What You Need?

• How Can We Help?
  To request more information about VLCT's Risk Management Services, complete and submit this form online.
• Request a Quote Online
  Complete and submit online for group life, short-term disability, and long-term disability.