Health Insurance Forms

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Full SNAP benefits for the month of November are expected to be available on EBT cards over the next couple of days. To check your balance, visit MyDSS.ct.gov or call 1-888-328-2666. If you need immediate food assistance, visit 211ct.org or ctfoodshare.org, or text the word FOODSHARE to 85511.

Health Insurance Forms

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