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Keenan Public Agencies Documents and Forms

Documents & Forms

Public Agencies

APPLE Beneficiary Designation and Change Form
Updated 4/15
APPLE Request for Refund of Contribution Form
APPLE Request for Settlement of Account – RSA
Updated: 5/20
APPLE Request Form
APPLE Required Minimum Distribution Request Form
APPLE Rollover Contribution Request Form
Social Security Form SSA-1945
PRIME Rx Temporary Prescription Services ID
Briefing – Division of Workers’ Compensation Amends MPN and Employee Information Regulations
Published 9/10
Compliance Kit Order Form
Revised 8/18
New Hire Pamphlet
Revised 6/20
Notice of Personal Chiropractor or Personal Acupuncturist
Notice of Potential Eligibility/DWC-1 Claim Form
Revised 1/1/16
Notice to Employees
Revised 8/18
Personal Physician Request and Acknowledgement Form
Revised 3/14
WC Benefits Summary
Revised 12/22
Workers’ Compensation Update: Important Changes to Predesgnation Regulations Effective 2014
Revised 2014
Briefing – Implementation of New MPNs effective 1/1/15
Published 12/14
PRIME Advantage MPN – Complete Written Employee Notification
Updated 3/23
PRIME Plus MPN – Complete Written Employee Notification
Updated 1/24
Benefit Eligibility Contributions Form
COBRA Administration Manual
Updated 2024
Hartford Life Administration Guide
Health Plan’s Authorization Form
HIPAA Resource Guide
Updated for 2010
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.
Prudential LTD Public Agencies Administrative Guide
Updated 8/15/11
Prudential STD Only or STD & LTD Public Agencies Administrative Guide
Updated 1/25/15