We recently updated our forms and applications. Please select the link for the applicable benefits in which you want to enroll and complete the application.

PLEASE NOTE: Applications marked with an asterisk (*) denotes the Pension Boards must be notified within 30 days of any change to benefits. Changes received after 30 days will be processed with a current effective date.

Enrollment Forms:

Dental Benefits Plan Enrollment Application Only - For enrollment period of October 14- November 14 of every Plan Year *

Claim Forms:

Member Submitted Dental Claim Form

Election Forms

To enroll in the Flexible Spending Account plan, please complete the Flexible Benefit Plan Election & Salary Redirection Agreement Form. - *For enrollment period October 14- November 14 of every Plan Year *

FSA Change in Status Form *

Health FSA

FSA Plan for UCC Ministries Medical Care Expense Claim Form

Qualifying Medical Care Expenses Worksheet

Dependent Care FSA

FSA Plan for UCC Ministries Dependent Care Claim Form

Qualifying Dependent Care Expenses Worksheet

Domestic Partnership Statement of Financial Interdependence Form *

Life Insurance (LIDI) Designation of Beneficiary Form

Life Insurance and Disability Income (LIDI) Benefit Plan Enrollment Application *

Life Insurance and Disability Income (LIDI) MetLife Enrollment Change Form

Optional & Additional Life Insurance Forms

Optional Additional Death Benefit Designation of Beneficiary Form

Statement of Dependent Eligibility Beyond Limiting Age in Plan Due to Mental or Physical Handicap

Statement of Health Form

Grants & Supplementation

Supplementation Application for Retirees (Ministerial Assistance)
Application for long-term financial assistance available to eligible retirees who are clergy, lay employees of a UCC congregation, or surviving spouses of the aforementioned. Support may include pension supplementation, health benefit assistance, monthly income supplementation, and an annual Christmas gift.

All questions need to be answered for us to process the application.

If you file taxes, you must submit tax form 1040 (Income Tax Return) with the application for verification of your income.

If you do not file taxes, you must submit a social security verification letter. 

We will follow up with you within 4-7 weeks on the status of your application.

Emergency Grant Request
Emergency assistance offered By UCBMA (United Church Board for Ministerial Assistance) & MBMA (Massachusetts Board of Ministerial Assistance) for unforeseen circumstances. Emergency Grant requests are generally considered once in a 12-month period. Requires Conference Minister Endorsement. We will follow up within 2-4 days upon receipt of Conference Minister Endorsement.

Ministerial Assistance Online Grant Directory
Directory of all grants offered by Ministerial Assistance. The login required for the directory and applying for grants is a separate account with Smarter Select and is not connected to your Pension Boards account.

We recently updated our forms and applications. Please select the link for the applicable benefits in which you want to enroll and complete the application. 

Enrollment Forms:

Medical (Non-Medicare) and Dental Benefits Enrollment *

Medicare Advantage Plan and Dental Benefits Enrollment Form *

Health Benefit Dependent Change Form *

Statement of Health Form

Small Employer Exemption (SEE) Form

Non-Medicare Medical Claim Form:

To obtain a member-submitted claim form or international claim form, please visit the Highmark website at www.highmarkbcbs.com or contact customer service at 866.763.9471 for assistance.

Pharmacy Claim Form:

To obtain a pharmacy reimbursement form, please login to your account at www.express-scripts.com or contact customer service at 800.939.3781 for assistance.

Other Health Plan Related Forms:

Domestic Partnership Statement of Financial Interdependence Form *

Health Benefits Automatic Credit Reduction Form

Protected Health Information Release Form