Documents and Forms

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Health & Welfare

Retirement
2017 Benefit Fund SPD Medical Info Release Form
Adding a Child to the Plan Form Normal - Disability Application
Adding a Spouse to the Plan Form Retirement Beneficiary Form
Applying for Weekly Disability Packet Retirement Election Form
ACH Authorization Insurance Payment Retirement Loan Application
Claim Form Retirement Survivor Benefits Application
Coordination of Benefits Question Rollover Election Form
Designating Your Beneficiary Form Sample QDRO
H&W Enrollment Form
HIPAA Authorization Form
HRA Claim Form
HRA Filing Instructions
Removing a Dependent Form
SavRx Reimbursement Form
Statement of Claim Form
Subrogation Form
Summary of Benefits - Active & Disabled Employees
Summary of Benefits – Surviving spouse program
Vision Claim Form

Delta Dental / VSP Vision Plan
Cover Letter - Delta Dental & VSP
Enrollment Form - Delta Dental & VSP
Rate Sheet - Delta Dental & VSP
Plan Information - Delta Dental
Plan Information - VSP
In order to serve you best,
please direct initial enrollment,
claims and/or payment questions to:

Delta Dental of Kentucky, Inc.
855-308-2299

If you have problems with enrollment, claims and/or payments,
please direct your questions to:

Darin Stanfield
502-736-7000