forms

Anthem

• Anthem claim form (medical services) | Medical PPO, HDHP, HDHP Basic
• Anthem claim form (medical services outside the U.S.) | If you receive medical services under your Medical PPO, HDHP, HDHP Basic while temporarily outside the U.S.
• Anthem claim for reimbursement of travel expenses | When Anthem has approved your medical claim for the related medical service, you can then submit a claim for reimbursement of qualifying travel expenses. Do not use the standard medical claim form to submit a travel benefit claim; your request will be denied. Be sure to read important rules and restrictions regarding this benefit prior to submitting a claim.
• Continuation of Care Application | Medical PPO, HDHP, HDHP Basic - Continuity of Care generally, applies to hospitalization, pregnancy, and treatment for a serious and complex condition. Transition Assistance is a process that allows continued care for participants when certain situations occur, such as: your primary provider is terminated from the participating provider network; you're a new enrollee in an Anthem plan and your primary provider is not part of the network; your continuity of care is at risk for reasons over which you have no control.

Cigna

• Cigna claim form (medical services) | Global Choice Plans (services inside or outside the U.S.)

Medical HMO - HMO Blue Texas

• Continuation of Care Application | Continuity of Care generally, applies to hospitalization, pregnancy, and treatment for a serious and complex condition. Transition Assistance is a process that allows continued care for participants when certain situations occur, such as: your primary provider is terminated from the participating provider network; you're a new enrollee in an Anthem plan and your primary provider is not part of the network; your continuity of care is at risk for reasons over which you have no control.

• Express Scripts claim form | Medical PPO, HDHP, HDHP Basic 
• Express Scripts claim form | Global Choice Plans (prescription drugs inside the U.S.)
• Cigna claim form | Global Choice Plans (prescription drugs outside the U.S.)

• Dental PPO (U.S.-Payroll Employees) Dental PPO (Delta) claim form | Orthodontic Treatment in Progress Claim
• Dental PPO (Expatriates in the U.S.) Dental PPO (Delta) claim form | Orthodontic Treatment in Progress Claim
• Dental HMO Continuous Orthodontic Care Request

• VSP claim form | Basic vision coverage for the Medical PPO, HDHP, HDHP Basic
• VSP claim form | Basic vision coverage for the Global Choice Plans
• VSP claim form | Vision Plus Program

The deadline to submit claims for out-of-network basic expenses is 365 days from the date of service. Keep in mind that you don’t always need to file a claim. If you received services from a network provider, a claim was automatically filed for you.

• Carelon claim form | MHSUD services in the U.S.
• Carelon claim form | MHSUD services outside the U.S.
• Carelon Claim for Reimbursement of Travel Expenses | When Carelon has approved your behavioral health claim for the related behavioral health service, you can then submit a claim for reimbursement of qualifying travel expenses. Do not use the standard medical claim form to submit a travel benefit claim; your request will be denied. Be sure to read important rules and restrictions regarding this benefit prior to submitting a claim.

• Anthem claim form | Health FSA
• Anthem claim form | Dependent Care FSA

• Critical Illness Insurance – Beneficiary designation form
• Critical Illness Insurance – Authorization for direct deposit form
• Critical Illness Insurance – Authorization to release personal health information
• Critical Illness Insurance claim form

• Hospital Indemnity Insurance claim form
• Hospital Indemnity Insurance – Beneficiary designation form
• Hospital Indemnity Insurance – Authorization for direct deposit form
• Hospital Indemnity Insurance – Authorization to release personal health information

• WIN Adoption Reimbursement Application - Use this form if you are enrolled in the Chevron Medical PPO Plan, the HDHP or the HDHP Basic
• Chevron Adoption Reimbursement Request - All other eligible employees should use this form.

• WIN Surrogacy Reimbursement Application - Use this form if you are enrolled in the Chevron Medical PPO Plan, the HDHP or the HDHP Basic
• Surrogacy Reimbursement Request - All other eligible employees should use this form.

• WIN Elective Fertility Preservation Reimbursement Application

• Affidavit of Domestic Partnership (Sample)
• Dependent Verification - Acceptable Proof (Sample)
• More about the Dependent Verification process

• Form W-2 details your compensation, tax withholding and required disclosures for the tax year. Instructions for W-2 state withholding (intranet only) 
• Federal tax withholding W-4   Go to Workday (intranet only) and select the Pay App, then click > Withholding Elections > Federal Elections
• State tax withholding  Instructions for state tax withholding elections (intranet only)

The Patient Protection and Affordable Care Act (ACA) requires that almost everyone in the U.S. have health coverage that qualifies as minimum essential coverage. U.S. taxpayers must be able to provide proof of such coverage for themselves and their dependents. Form 1095 reports information about offers of health coverage and enrollment in health coverage for federal tax purposes.

Form 1095 information and instructions

If you have prior service with Chevron – either as an employee, a contractor or a leased employee - you may be eligible to receive additional service credit for some of your benefits like retirement or vacation. This credit is not automatic; you must apply to request a review of your situation before a determination can be made. If you believe this situation applies to you, please return the applicable form within 60 days from your date of hire. The information you provide on your application will help Service Administration determine if your prior service meets the criteria to receive service credit under certain Chevron benefit plans or policies. Service Administration will notify you of the results via U.S. mail.

Prior Service History Form (F36)*
Complete this application if you have prior employment with Chevron Corporation, a Chevron Corporation acquired company, and/or a Chevron Corporation affiliated company.

*Read the description of each form carefully to determine which form(s) match your situation. You can complete both forms (F-36) and (F-08) if you have both prior leased employee service and prior employment. Otherwise, simply complete the one form that matches your situation.

For short-term and long-term disability cases

• Attending physician/Health care provider form. Your doctor(s) needs to complete this form in order to provide medical certification and documentation of your disability, as required under the provisions of the Chevron Short-Term Disability (STD) and Long-Term Disability (LTD) Plans. If you are under the care of more than one doctor or caregiver, each of them must complete and submit this form. This form should be used if the cause or nature of your medical condition and related disability is due to a physical sickness or injury.


• Behavioral health attending physician's statement form. Your doctor(s) need to complete this form in order to provide medical certification and documentation of your disability, as required under the provisions of the Chevron Short-Term Disability (STD) and Long-Term Disability (LTD) Plans. If you are under the care of more than one doctor or caregiver, each of them must complete and submit this form. This form should be used if the nature of your medical condition and the related disability is due to a mental health or substance abuse problem.

For FMLA and related state leave laws, including California paid family leave (PFL)

• Personal medical certification of health care provider form
• Family member medical certification of health care provider form
• Military family member certification form
• Military caregiver medical certification of health care provider form
• Bonding for birth, adoption or placement of a child medical certification of health care provider form
• California Disability Insurance Coverage Change Request (Form F-66)

If you are taking time off for a reason that's covered under the Family and Medical Leave Act of 1993 (FMLA) or a related state leave law, you need to submit the appropriate form to provide the necessary certification and documentation in support of your absence. Most of them require a licensed physician to complete a section of the form.

If you want to change from the Chevron Voluntary Disability Insurance Plan (voluntary plan) to the California State Disability Insurance Program (SDI), or vice versa:

• Complete and return form F-66 California disability insurance coverage change request form. The change will be effective the first day of the next calendar quarter.