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Insurance Forms Document Center

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This document center includes frequently used forms for all the plans provided through the Chemung County Insurance Department. If you are not sure which forms you should complete, refer to your union or group plan summary (links below) with plan lettering to verify which plans pertain to you or contact the Chemung County Insurance Department. 

      Chemung County Employee Benefits

      Muncipality/Special District Employees

Eligibility requirements should be discussed with the Chemung County Insurance Department or your participating employer group.

Refer to the Subscriber Responsibility for dependent eligibility and required documentation.

All enrollment forms must be returned to the Chemung County Insurance Department for processing. Do not submit them directly to your insurance plan carrier.  The 'other insurance coverage information' form should be completed every time you complete enrollment forms.

All claim forms are sent to your insurance plan carrier directly.  Do not send them to the Chemung County Insurance Department.

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Document Center

The Document Center provides easy access to public documents. Click on one of the categories below to see related documents or use the search function.

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Categories always sorted by seq (sub-categories sorted within each category)
Documents sorted by SEQ in Ascending Order within category
Please click on one of the categories below to see uploaded documents.
A, B, C, H, I - Chemung County Forms 4 documents
CAT:108
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This form must be completed with enrolment forms – RETURN FORM TO THE CHEMUNG COUNTY INSURANCE DEPARTMENT.
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file:109
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This form must be completed with enrolment forms - RETURN FORM TO THE CHEMUNG COUNTY INSURANCE DEPARTMENT.
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file:110
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RETURN FORM TO THE CHEMUNG COUNTY INSURANCE DEPARTMENT
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file:112
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The acknowledgment form must be completed with enrollment forms
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file:113
A, B, C, H, I - EXCELLUS Forms 3 documents
CAT:114
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file:115
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RETURN FORM TO EXCELLUS DIRECTLY
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file:116
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RETURN FORM TO THE CHEMUNG COUNTY INSURANCE DEPARTMENT
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file:117
A, B, C - EXCELLUS Classic Blue, Blue PPO, Blue PPO 2, Rx Plan Forms 3 documents
CAT:118
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file:119
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RETURN FORM TO EXCELLUS DIRECTLY
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file:120
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RETURN FORM TO EXPRESS SCRIPTS DIRECTLY
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file:121
H, I - EXCELLUS Medicare Blue PPO Plans Forms 1 documents
CAT:122
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RETURN FORM TO THE CHEMUNG COUNTY INSURANCE DEPARTMENT.  Claim form for the Medicare Blue PPO Plan - contact Excellus Customer Service at (866) 846-8643.
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file:123
D, E  - LIFETIME BENEFIT SOLUTIONS Forms (LBS) 4 documents
CAT:124
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RETURN FORM TO THE CHEMUNG COUNTY INSURANCE DEPARTMENT
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file:125
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RETURN FORM TO THE CHEMUNG COUNTY INSURANCE DEPARTMENT
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file:126
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RETURN FORM TO EBS DIRECTLY
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file:127
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RETURN FORM TO EBS DIRECTLY
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file:128
F - CSEA PLATINUM 12 VISION Form 1 documents
CAT:129
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RETURN FORM TO THE CHEMUNG COUNTY INSURANCE DEPARTMENT.  NOTE: Please contact CSEA Platinum 12 Vision Plan directly for claim forms and student dependent certification requirements.
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file:130
A, B, C (optional H, I) - MAIL ORDER Forms 2 documents
CAT:131
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file:132
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file:133
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Chemung County

"It gives me great pleasure to welcome you to ChemungCountyNY.gov, the virtual entrance to various programs and services available through Chemung County government. This site was designed to provide you with “user-friendly” access to a variety of links to different offices and organizations that are involved with tourism, economic and community development, transportation, health and social services.Thank you for visiting ChemungCountyNY.gov!"

Chemung County
203 Lake Street
Elmira, NY 14901

person
County Executive Thomas J. Santulli