Keenan Schools - Documents and Forms

Documents & Forms

APPLE
Workers' Comp
WC Claims Kit
Benefits

Name	Protected	Download		Notes
		English	Spanish
APPLE Beneficiary Designation and Change FormNeed to change your beneficiary on your APPLE plan? Download this form.
APPLE Request for Settlement of Account (RSA)Request a distribution from your APPLE plan.
APPLE Rollover Contribution Request FormRoll funds into your APPLE plan from another qualified plan.
APPLE Request for Refund of Contribution FormPlan Sponsor form to request a refund of contributions made in error.
APPLE Request FormGet a quote to see how an APPLE plan can benefit your organization.
APPLE Participant Web Site Access Instructional FlyerInstructions for APPLE plan members to access their account info online.
APPLE Plan Sponsor Web Site Access Instructional FlyerInstructions for APPLE plan sponsors to access the management website.

Name	Protected	Download		Notes
		English	Spanish
PRIME Rx Introductory LetterIntroduction to Prime Rx for program administrators.
PRIME Rx Temporary Prescription Services IDWC Temporary Prescription Services ID form that can be presented to your pharmacist when you fill your initial prescription using the Prime Rx program.

Name	Protected	Download		Notes
		English	Spanish
Briefing - Predesignations March 2006These rules and regulations provide clarification regarding how an injured employee must predesignate their personal treating physician and exactly what type of physicians can be predesignated.				Published 3/06
WC Benefits SummaryInformation about your Workers' Comp benefits.				Revised 7/10
Posting NoticeFlyer to post that explains what to do when an injury occurs at work.				Revised 9/10
New Hire PamphletHand-out for employees that explains Workers' Comp benefits.				Revised 8/10
Personal Physician Request and Acknowledgement FormYou must notify your employer ,in writing, prior to being injured on the job and provide written verification that your personal physician meets the above requirements and agrees to be predesignated to be eligible.				Revised 7/07
Notice of Personal Chiropractor or Personal Acupuncturist FormTo be eligible you must notify your employer in writing prior to being injured.
Notice of Potential Eligibility/DWC-1Instructions for submitting a Workers' Comp claim.				Revised 8/10
DWC-1 Claim FormState of California Workers' Comp Claim Form.				Revised 8/10
Compliance Kit Order FormOrder printed copies of the WC forms to be mailed to your organization.				Revised 8/10

Please click here for directions on how to access and download forms within an Administrative Guide marked with an asterisk (*).

Name	Protected	Download		Notes
		English	Spanish
Blue Shield - Life (formerly CPIC) Admin. GuideThis Admin Guide is designed to assist you in the administration of your Blue Shield of California Life & Health Insurance Company (Blue Shield Life) Life Benefits.				effective 7/1/05
COBRA Continuation Coverage Administration ManualQuick reference and easy access to the tools you need for COBRA administration.				updated for 2010
COBRA Continuation Coverage Administration Manual FormsQuick reference and easy access to the tools you need for COBRA administration.				updated for 2010
Health Plan's Authorization FormThis form is used to request an individual’s unconditioned authorization for the Health Plan to use or disclose protected health information for the purpose stated.
HIPAA Resource GuideInformation guide about HIPAA regulations.				updated for 2010
MES Administrative GuideAdministrative guide for Medical Eye Services.				updated 9/14/09
MetLife Admin GuideThis Admin Guide is designed to assist you in the administration of your MetLife Insurance Program.				updated 9/15/08
^*Prudential Basic Life & AD&D Admin. GuideThis Admin Guide is designed to assist you in the administration of The Prudential Insurance Company of America Basic Life and AD&D Program.				effective 7/1/05
Prudential Schools Contributory LTD Admin. GuideThis Admin Guide is designed to assist you in the administration of The Prudential Insurance Company of America Contributory LTD Program.				effective 7/29/09
Prudential Schools Non-Contributory LTD Admin. GuideThis Admin Guide is designed to assist you in the administration of The Prudential Insurance Company of America Non-Contributory LTD Program.				effective 7/6/09
Prudential Schools Non-Contributory STD-LTD Admin. GuideThis Admin Guide is designed to assist you in the administration of The Prudential Insurance Company of America Non-Contributory STD-LTD Program.				effective 7/6/09
Prudential Schools Voluntary AD&D Admin. GuideThis Admin Guide is designed to assist you in the administration of The Prudential Insurance Company of America Voluntary/Optional Life Program.				updated 4/1/10
^*Prudential Voluntary/Optional Life Admin. GuideThis Admin Guide is designed to assist you in the administration of The Prudential Insurance Company of America Voluntary/Optional AD&D Program.				effective 7/1/05