Documents & Forms

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

Schools & Colleges

Health Care | Public Agencies
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APPLE Account Authorization for Direct Deposit PDF
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 7/16
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  
Blue Shield – Life PDF   updated 8/14
COBRA Administration Manual PDF   Updated for 2015
Hartford Disability Admin Guide PDF   updated 10/20/2016
Hartford Life Administration Guide URL  
Health Plan’s Authorization Form Word  
HIPAA Resource Guide PDF   updated for 2010
MES Administrative Guide PDF   updated 9/14/09
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Auto Accident Pamphlet PDF  
Claims Reporting After Hours Procedure PDF  
Claims Reporting Procedures PDF  
HSB Claim Filing Guide PDF  
HSB Claim Form PDF  
Property Claim Form PDF  
Third-Party Liability Claim Form PDF