Millenium Insurance Group

Trust is our foundation, Service our dedication

Forms

The following forms are available for download in Adobe Acrobat (PDF) format. In order to view these files, you will need Acrobat Reader. If you do not have Acrobat Reader, please click the logo to the right to download it for free.

Capital Blue Cross

Application to Enroll or Change Enrollment
2006 Preferred Medication List

CareMark

Mail Order Form
Prescription Drug Reimbursement Form

Highmark

Authorization for Disclosure of Health Information

HealthAmerica

Small Group Employee Application
Member Designated Release of Information
Vision Claim Form
Enrollment/Change Form

Aetna

Commercial Prescription Drug Claim Form
Dental Enrollment/Change Request
Conversion of Group Term Life Insurance
Enrollment/Change Request

United Concordia

Dental Enrollment Form
Dental Claim Form
Dependent Certification Form

Davis Vision

Member Change Form

Assurant

Assurant Employee Application
Fortis Faxable Change Form
Medical Claim Form

Genworth

Enrollment Request Form
Voluntary Benefits Group Life Enrollment Request
Employee Change Form

HIPAA Confidentiality

HIPAA Confidentiality Form

Millenium Insurance Group, Inc. • 135 East Main Street • New Holland, PA 17557
Phone (717) 354-4774 • Fax (717) 354-0459 • Toll-Free (888) 577-7373 • E-Mail lbracelin@millig.com