Welcome to the Forms Page! 

 

 

Enroll / Change

ENROLLMENT WEBSITE

 

Domestic Partner Affidavit

 

Termination of Domestic Partnership

 

HSA Change Form

Medical Opt-Out (you must also WAIVE medical in the online enrollment system)

 
Life

Change your beneficiary

Note: If you are married and want to designate someone other than your spouse as a primary beneficiary, contact the Benefits Office: benefitquestions@tucsonaz.gov

 

Evidence of Insurability : Employees who requested to add/increase supplemental or spouse life during Open Enrollment receive instructions by mail. Deadlines exist.

Waiver of Premium (in case of disability)

Deadlines exist.

 

Portability or Conversion Application: Contact Benefits OfficeDeadlines exist.
Disability Evidence of Insurability: Employees who requested to increase LTD during Open Enrollment receive instructions by mail. Deadlines exist.

POLICY #: 395200

LTD Claim Form

*See detailed instructions, below

You can also Start Your Claim or Check Claim Status online

   
Other Medical / RX Forms FSA Forms Retiree Forms  

 

* File an LTD Claim: Because The Hartford is not the City's short term disability carrier, they will need to collect from you full information about your condition.  It is recommended that you begin the claim process half way through your waiting period (45 days if you have the 90-day Buy Up waiting period or 3 months if you have the 6-month Basic LTD waiting period.)  

 

Hartford Long Term Disability Claim Form

  • You complete:
    • The personal information (top of form)
    • Section 1 A (group number is 395200)
    • Section 1 C (the answer is "NO")
    • Section 1 F (If you have questions, please call the Pension office at 791-4598.)
    • Section 1 G (Return to work manager is Eric Kay: 520-837-4168.)
    • Section 1 K
    • Section 2
  • Work with your physician to complete the medical information section
  • Your manager or payroll clerk completes
    • Section 1 E (For Worker's Comp information, please call 791-2619.)
    • Sections 1 H, I and J (For information about work accommodation, please call 791-2619.)
  • Benefits Office Staff completes
    • Sections 1 B and D

Submit your completed form to:

The Hartford
PO Box 14302

Lexington, KY 40512-4302
Phone: 1.800.289.9140
Fax: 1.866.583.8237