Customer Service Forms

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 Form
  Download, 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 Form
  Download, print and complete.

Vision

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

VLCT PACIF

• General Coverage Questions
  Complete and submit online.
• Certificate of Insurance Request
  Complete and submit online.

Workers’ Compensation

• First Report of Injury Form
  Complete and submit online.
• Non-Employee Work Agreement
  Download, print and complete.

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

• 2009 UI Wage Report (Excel spreadsheet)
  Download, complete and return to VLCT via email, fax or U.S. mail.
• 2009 UI Wage Report
  Download, print and complete.