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Forms & Documents At Diversified Group Brokerage Corporation, we want all our Clients and Members to find managing benefits as simple and positive an experience as possible. For your convenience, we have posted the forms and documents most often used by our Members and Clients. If you are currently logged in, your available Summary Plan Document, Schedule of Benefits and related Amendments are listed here as well. |
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Forms
Application for Disabled/Handicapped
Attending Dentist's Statement
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196 K
COBRA Administration Termination Form
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630 K
Continuation of Coverage Election Form
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492 K
Dependent Eligibility Form
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587 K
Election Of Coverage for An Active Employee
Group Enrollment Form
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473 K
Group Enrollment/Diverse-Choice Form
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484 K
Hospital and Medical Claim Form
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567 K
HRA Account Reimbursement Request Form
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16 K
Medical & Dental Supplement Coverage Only
Medical Supplement Coverage Only Enrollment
Notice of Termination Form
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198 K
Section 125 (Flexible Spending) Employee
Section 125 (Flexible Spending) Proof of
Section 125 (Flexible Spending)
Spousal Eligibility Form
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341 K
Weekly Disability Income Claim Form
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23 K
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Info About Your Benefits Info About Your Benefits is only available if you log in.
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