Forms

GTFF Health Insurance Enrollment Form

Medical Claim Form

NO LONGER REQUIRED!  I would include a copy/scan of your insurance card for the first page however.

Dental plan change form

(CAN ONLY SWITCH PLANS STARTING FALL TERM)

Affidavit of Domestic Partnership

(you’ll also need enrollment application filled out)

2020-2021 Payroll Deduction Form

NOTE: if a NEW GE who has not been on plan before, you NEED to fill out APPLICATION first.


If you have questions, you can contact Glenn Morris, our health care administrator, at (541) 344-0832 or via email at benefits@gtff.net.

Forms and more can also be found on the Pacific Source Website: http://www.pacificsource.com/member/oregon/forms-and-materials.aspx

VARIABLE PREMIUM PAYMENT OPTION–check in with Glenn before using! (If paying just for summer, use the Summer Premium Payment option in the Health Care Menu drop down!)