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 8/18
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
Notice to Employees PDF PDF Revised 8/18
Personal Physician Request and Acknowledgement Form Word Word Revised 3/14
WC Benefits Summary PDF Revised 7/18
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 2018
Hartford Life Administration Guide URL  
Health Plan’s Authorization Form Word  
HIPAA Resource Guide PDF  
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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