Self-Funded Forms

• Self-Funded COVID-19 Testing Reimbursement Form
• Claim Form - Disability
• Self-Funded Group Enrollment Form

Preferred United Plans "Alternative Funding" Forms

• PUP COVID-19 Testing Reimbursement Form

  Michigan and Kentucky

• ​Request for Proposal 
• Employer Application 
• Employee Health Questionnaire​​ 

Benefit Summaries (MI & KY)

• PPO – 100%, 90%, 80% or 70%
• HSA – 100% or 80%​

  Ohio

• Request for Proposal 
• Employer Application 
• Employee Health Questionnaire 

Benefit Summaries (OH)

• PPO – 100%, 90%, 80% or 70%
• HSA – 100% or 80%

Flexible Spending Forms

• Flexible Spending Claim Form