Select from the forms below (each form opens in a new browser window).

• Accidental Death and Dismemberment (AD&D) Conversion Form
  This form should be completed if you would like to convert all or a portion of the terminating coverage to an individual policy (subject to conversion amount limitations). Amounts you convert are no longer part of your Northrop Grumman coverage, and you are solely responsible for keeping the individual policy(ies) active. You pay the insurance company directly. Your cost is based on the insurance company’s standard individual rates, which may differ from the rates you currently pay.
• Aetna Global Benefits Claim Form
  This form should be completed when you have paid for services and need to request reimbursement. When seeking care in the US, Aetna Network providers will generally submit your claims directly to Aetna Global Benefits eliminating the need for you to do so. Requests for reimbursement should be faxed or mailed to the address(es) shown on the form.
• Anthem Blue Cross Claim Form
  This form should be completed if you utilize providers not in the Anthem Blue Cross network.  Network providers generally submit your claims directly to Anthem. Please call the Anthem Blue Cross customer service number listed on your Member ID card for the claims office address.  Claims should be mailed to the Blue Cross and/or Blue Shield Plan of the state in which services were received. 
• Anthem Disabled Dependent Certification Form
  This form should be submitted to Anthem Blue Cross to certify eligibility for a disabled dependent child.  Generally, unmarried disabled dependent children may be covered under the Northrop Grumman Health Plan, regardless of age or student status, if the disability occurred before age 19 (age 25 if a full-time student).  Please see summary plan description or contact the Northrop Grumman Benefits Center for more details. 
• Benesyst Flexible Spending Account (FSA) Claim Forms
  Use these forms if you are currently enrolled in either the Dependent Day Care or Health Care FSA to submit claims for reimbursement of eligible expenses. Please be sure to attach the necessary documentation.
  • Dependent Day Care
  • Health Care

• Benesyst Flexible Spending Account (FSA) Direct Deposit Form
  Use this form if you are currently enrolled in either the Dependent Day Care or Health Care FSA and would like to have Direct Deposit of your FSA reimbursements. Direct Deposit is an added service that was designed to save you time in handling your reimbursement checks. Please be sure to attach the necessary documentation.
• Blue Cross Blue Shield (BCBS) Claim Form
  This form should be completed only if you utilize providers not in the BCBS Point of Service (POS) or Preferred Provider Organization (PPO) networks. Network providers generally submit your claims directly to BCBS. You may also need to use this form for hearing claims. Mail to the address shown on the form.
• Delta Dental Claim Form
  This form needs to be completed only if you use a dentist who does not participate in the Delta Dental Network of Providers. Delta network providers will file the claim for you.
• Evidence of Insurability (EOI) Form (Optional Life)
  This form needs to be completed if you select Optional Life Insurance in excess of five times your annual base pay or $600,000, whichever is less. If you select Spouse Life Insurance in excess of $50,000, you also must complete this form.
• Express Scripts Claim Form
  This form needs to be completed any time you use a pharmacy that does not participate in the Express Scripts Network or if your in-network pharmancy claim was not be submitted electronically.
• Express Scripts Home Delivery Prescription Order Form 
  Use this form to order prescription drugs through Express Scripts Home Delivery Program.
• Express Scripts Proof of Benefits Form
  If you have not received your ID card, please present this letter to your Express Scripts network pharmacist beginning July 1, 2006, to accurately process your prescriptions.
• HIPAA Authorization Form
  This form allows you to give authorization to Use and/or disclose personal health plan information.
• HMO/EPO Primary Care Physician (PCP) Designation Form (for under age 65 retirees only)
  This form is used to select a primary care physician if you and/or your dependent(s) are enrolled in an HMO/EPO.
• Life Insurance Conversion form
  This form should be completed if you would like to convert all or a portion of the terminating coverage to an individual policy (subject to conversion amount limitations). Amounts you convert are no longer part of your Northrop Grumman coverage, and you are solely responsible for keeping the individual policy(ies) active. You pay the insurance company directly. Your cost is based on the insurance company’s standard individual rates, which may differ from the rates you currently pay.
• Life Insurance Portability form
  This form should be completed if your employment ends and you wish to continue all or a portion of your optional life insurance (for yourself, your spouse and/or your dependents) under the Northrop Grumman Health Plan when that coverage would otherwise terminate. You pay the insurance company directly. Your cost is based on the insurance company’s standard group rates, which may differ from the rates you currently pay.
• LTD Claim Form (Corporate and IS)
  This form needs to be completed when filing a Long-Term Disability claim. You must complete this form in order for UnumProvident to obtain your medical records from your physician.
• MetLife Conversion Form
  This form is used to convert your group life insurance with MetLife to an individual policy.
• Primary Dental Care/CIGNA
  CIGNA network providers must file the claim for you (no form available).
• Special Notice about Medicare Prescription Drug Choices
  This notice applies to you and/or your covered family members who are eligible for Medicare.
• Tricare Supplement Claim Form
  This form should be completed if your provider does not file for the balances which remain after Tricare has made their payment. Mail your completed claim to the address shown on the form and include copies of all applicable bills, Tricare Explanations of Benefits, and receipts from the provider for paid copay amounts.
• VSP Claim Form
  This form needs to be completed only if you use a provider who does not participate in the VSP network. VSP providers will file the claim for you.