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Public Agencies
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Apple
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Benefits
English
APPLE Beneficiary Designation and Change Form
Updated 4/15
English
APPLE Request for Refund of Contribution Form
English
APPLE Request for Settlement of Account – RSA
Updated: 5/20
English
APPLE Request Form
English
APPLE Required Minimum Distribution Request Form
English
APPLE Rollover Contribution Request Form
English
Social Security Form SSA-1945
English & Spanish
PRIME Rx Temporary Prescription Services ID
English
Briefing – Division of Workers’ Compensation Amends MPN and Employee Information Regulations
Published 9/10
English
Compliance Kit Order Form
Revised 8/18
English
Spanish
New Hire Pamphlet
Revised 6/20
English
Spanish
Notice of Personal Chiropractor or Personal Acupuncturist
English
Notice of Potential Eligibility/DWC-1 Claim Form
Revised 1/1/16
English
Spanish
Notice to Employees
Revised 8/18
English
Spanish
Personal Physician Request and Acknowledgement Form
Revised 3/14
English
WC Benefits Summary
Revised 12/22
English
Workers’ Compensation Update: Important Changes to Predesgnation Regulations Effective 2014
Revised 2014
English
Briefing – Implementation of New MPNs effective 1/1/15
Published 12/14
English
Spanish
PRIME Advantage MPN – Complete Written Employee Notification
Updated 3/23
English
Spanish
PRIME Plus MPN – Complete Written Employee Notification
Updated 3/23
English
Benefit Eligibility Contributions Form
English
COBRA Administration Manual
Updated 2018
English
Hartford Life Administration Guide
English
Health Plan’s Authorization Form
English
HIPAA Resource Guide
Updated for 2010
N/A
Prudential Basic Life/AD&D, Optional Life/AD&D Public Agencies Administrative Guide
This guide is being updated. Please contact your Keenan Service Representative for assistance.
English
Prudential LTD Public Agencies Administrative Guide
Updated 8/15/11
English
Prudential STD Only or STD & LTD Public Agencies Administrative Guide
Updated 1/25/15
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