South Carolina Department of Public Safety

Human Resource Forms - Benefits

• Active Notice of Election Form
• COBRA Notice of Election Form
• Personal Health Statement ( Hartford Life)
• Student Certification Form
• Dependent Social Security Number Form
• Incapacitated Child Certification Form
• Request for Blue Cross and Blue Shield Card
• State Health Plan Claim Form
• State Dental Plan Claim Form
• Coordination of Benefits Form - Direct Claim Form
• Prescription Drug Home Delivery Order Form

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