Forms

These forms and employee notices are available for download via this website for your convenience. If you have any questions as to their use, please allow a NAA associate to help facilitate the submission. Click on a form in the list below to download a PDF.

For assistance or questions regarding any of the below, call our Customer Service Department at
1-800-411-3650.


Claims Forms
Dental Claim Form – full-time student information included
Dental Claim Form – no full-time student information
Flex Claim Forms (Health FSA and Dependent Care Account)
Medical Claim Form
Short Term Disability Claim Form
Vision Claim Form – full-time student information included
Vision Claim Form – no full-time student information
Eligibility Forms
Change Form – full time student information included
Change Form – no time student information
Enrollment Form
Dependent Information Form
Dependent Information Form – Spouse
Employee Notices
Required Employee Notices – Schedule
Initial COBRA Notice
HIPAA Special Enrollments Rights
HIPAA Notice of Privacy Practices
Model CHIP Notice
Model Individual Notice – Medicare Part D Creditable Coverage
Model Individual Notice – Medicare Part D Not Creditable Coverage
Women’s Cancer Rights
Spanish Forms
Enrollment Form – full time student informaiton included
Enrollment Form NEW – no full time student
Change Form NEW – no time student information
Dental Claim Form
Medical Claim Form
Additional Forms and Information
Life and Long Term Disability Claim Forms
Exchange Notice
Link to Guardian Forms Website
Link to Mutual of Omaha Forms Website
Lab Card/Lab Card Select Benefit
Lab Card Information for Employers
Lab Card Select Information for Employers
Physician Education
Miscellaneous
W-9 Form – Provider Identification