Forms
Discover the comprehensive employee benefits packages we offer to support your well-being.
Enrollment - New Hire / Change
Verdegard Enrollment Form
Add / Delete Indpendents
Affirmation of Common-law Marriage
A Navajo Tribal Court divorce decree is required for determination of a number of employee benefits
Affirmation of Common Law Procedures
The Common Law Marriage Procedures allow eligibile employees of the Navajo Nation Government, it Enterprises and Entities the opportunity to elect coverage for common law spouse.
CMS Data Collection for Section 111 Compliance
This ALERT is to advise that collection of SSNs, HICNs, or EINs for purposes of compliance with the reporting requirements under Section 111 of Public Law 100-173 is appropriate.
Medicare D Notice
. This notice has information about your current prescription drug coverage with Navajo Nation Employee Benefit Plan and about your options under Medicare’s prescription drug coverage.
NNEBP Benefit Pamphlet
Handout Brochure.
Summary of Benefits Coverage
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Health Benefit
Native Traditional Healing Reimbursement
NATIVE TRADITIONAL HEALING BENEFIT REIMBURSEMENT FORMs
Native Traditional Healing Procedures
The Navajo Nation Native Healing Benefit Plan is developed to provide reimbursement for expenses resulting from native healing ceremonies.
Coordination of Benefits Questionnaire
We need your help to determine your primary health insurance coverage by completing and returning the attached form.
Explanation of Benefits Statement
Explanation of Benefits (EOB) Reference Guide.
Verdegard Third Party Liability Questionnaire
To help manage your healthcare costs, our plan may recover benefits paid if a third party is responsible for your medical expenses.
Health Care Provider Nomination PNOA
Enroll a healthcare provider in the PNOA network by completing and submitting this form.
Medical, Dental & Vision Reimbursement
REQUEST FOR OUT-OF-POCKET REIMBURSEMENT FOR HEALTH SERVICES or SUBMISSION OF ITEMIZED HEALTH CLAIM
Pharmacy Benefit
MedImpact Pharmacy Reimbursement
Commercial Prescription Drugs Claim Form
Medimpact Home Test Kit Reimubursement
Commercial at-home over-the-counter COVID-19 test reimbursement form
MedImpact Prescription Mail Order Instructions
Simplify your medication management with MedImpact Direct Mail. Enjoy the convenience of having up to a 90-day supply of your prescriptions delivered right to your door. Easily manage refills, track orders, and access helpful tools through their user-friendly website or mobile app.
MedImpact Prescription Mail Order Form
MedImpact Direct offers an enrollment form for ordering medications, allowing customers to provide payment information, request Easy Open Caps, and authorize charges for prescriptions
Member Portal
HIPAA Release Form for Member Portal
This form is used to confirm a Member's permission that the health plan may discuss or disclose
their protected health information to a particular person who acts as their Authorized Representative.
HMA Member Portal Instructions
Access medical benefit information 24/7 via HMA’s online portal. View claims, prior authorizations, benefit details, and more.
Life
Metlife Beneficiary Designation
This form allows you to designate beneficiaries to receive your life insurance proceeds after your death, including primary and contingent beneficiaries1. You’ll need to provide accurate information for each beneficiary and ensure the total proceeds assigned to them add up to 100%
Metlife Addendum - Primary Beneficiary
The PDF form designates beneficiaries, including their personal information and assigned proceeds percentages, with a required signature from the insured owner.
Metlife Addendum - Secondary Beneficiary
The PDF contains information about contingent beneficiaries, including their names, addresses, dates of birth, and assigned percentages of proceeds. The insured/owner must sign the form to designate beneficiaries.
Metlife Claim – Employer’s Statement
Employers or benefit administrators must complete a form and submit it along with relevant documents to MetLife for life insurance claims. Claimants receive specific documents, and multiple claimants can submit separate forms.
Metlife Claim – Claimant’s Statement
MetLife offers a Total Control Account (TCA) for life insurance claim proceeds, providing immediate access to funds through a TCA Visa debit card or drafts, along with bill payments and beneficiary designation.
Metlife Accidental Dismemberment
The PDF contains information about a specific topic, but further details are not provided in the current context.
Metlife Accelerated Benefit Option
The Accelerated Benefits Option (ABO) allows eligible individuals with terminal illnesses to receive a portion of their Group Life Insurance benefits1. Claimants must complete the necessary forms and submit them to their employer for processing.
Metlife Beneficiary Grief Counseling
MetLife Life Insurance Beneficiary Grief Counseling: MetLife offers free grief counseling services to beneficiaries of their life insurance coverage.
Supplemental
Metlife Optional Term Life Application
This form allows employees to request coverage for life insurance benefits, including supplemental life insurance for themselves, dependent spouse, and children. It also includes beneficiary designation and fraud warnings.
Metlife Optional Term Life Statement of Health
The form is related to group insurance enrollment and requires health information. It includes sections for personal details, health history, and authorization.
Metlife Optional Term Life Cancellation
The document notifies MetLife about changes or terminations related to an Optional Term Life policy, including details such as policy holder information, dependent names, and reasons for cancellation.
Colonial Cancellation Form
The form allows policyholders to request various changes, such as name or address updates, premium payment method changes, policy loans, and withdrawals.