Health Insurance Forms

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Extremely dry conditions have Connecticut at an elevated level of fire risk:

- Governor Lamont declared a State of Emergency to help with any needed response. [Read more]
- DEEP has implemented a burn ban (outdoor grills, firepits, campfires, etc.) at all state parks, forests, and wildlife management areas. [Read more]

Health Insurance Forms

Effective June 29, 2020 Our New Mailing Address is:

CT Teachers' Retirement Board
165 Capitol Avenue
Hartford, CT 06106-1673

TRB Forms

Application for $440 Health Insurance Subsidy
Certification of Residence Form
Health Insurance Application
Health Insurance Cancellation Form
Debit Authorization Form Only for dependents who are Manually Billed for Health Premiums

Providers Claim Forms

UHC Direct Member Medical Reimbursement Form

Connecticut Teachers' Retirement Board