Documents & Forms

Keenan provides you with online access to the forms you need to manage your Workers’ Comp and Benefits programs.

Public Agencies

Schools & Colleges | Healthcare
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APPLE Beneficiary Designation and Change Form PDF Updated 4/15
APPLE Request for Refund of Contribution Form PDF
APPLE Request for Settlement of Account – RSA (Updated: 11/10/15) PDF
APPLE Request Form Excel
APPLE Rollover Contribution Request Form PDF
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PRIME Rx Introductory Letter PDF
PRIME Rx Temporary Prescription Services ID PDF
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Briefing – Division of Workers’ Compensation Amends MPN and Employee Information Regulations PDF Published 9/10
Compliance Kit Order Form Word Revised 1/1/16
New Hire Pamphlet PDF PDF Revised 7/16
Notice of Personal Chiropractor or Personal Acupuncturist Form Word Word
Notice of Potential Eligibility/DWC-1 Claim Form PDF Revised 1/1/16
Personal Physician Request and Acknowledgement Form Word Word Revised 3/14
Posting Notice PDF PDF Revised 1/1/16
WC Benefits Summary PDF Revised 7/17
Workers’ Compensation Update: Important Changes to Predesgnation Regulations Effective 2014 PDF Revised 2014
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Briefing – Implementation of New MPNs effective 1/1/15 PDF   Published 12/14
PRIME Advantage MPN – Complete Written Employee Notification PDF PDF Updated 2/16
PRIME Plus MPN – Complete Written Employee Notification PDF PDF Updated 2/16
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Benefit Eligibility Contributions Form PDF  
COBRA Administration Manual PDF   Updated for 2015
Hartford Life Administration Guide URL  
Health Plan’s Authorization Form Word  
HIPAA Resource Guide PDF   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 PDF   updated 8/15/11
Prudential STD Only or STD & LTD Public Agencies Administrative Guide PDF   updated 1/25/13
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Notes