Benefits Forms & Links

If you cannot read any of these files after downloading them, please call Human Resources at ext. 7757 and request the appropriate form.

Health Insurance - Blue Cross

• 2012 Medical Election Form - Sample
• Enrollment & Change Form - Sample
• Cancellation Form
• Provider Link
• Medical Claim Form
• International Claim Form  - Phone: 1-800-810-2583
• Authorization Delegate Form (HIPAA)
• Prescription Claim Form
• Magellan Mental Health Link  - Phone: 1-800-991-5638
• Express Scripts New Order Form

Dental Insurance - Cigna

• Enrollment & Change Form
• Provider link 
  
• PPO Claim Form
• PPO Summary
• PPO ID Card (generic)
• 2012 DHMO Charge Schedule

Flexible Spending Account(s) - Ceridian

• 2012 Enrollment Form
• Direct Deposit
• Benefit Card Information
• Additional Benefit Card Enrollment Form
• Participating Benefit Card Merchant Listings
• Sample Health Care Expense Eligibility
• Status Change Form
• Medical Reimbursement Form
• Dependent Care Reimbursement Form

Davis Vision - New Vendor effective 1/1/2012

• 2012 Davis Vision Enrollment Form
• Davis Vision Benefit Flyer
• Provider Link - On the member tab, enter client code 2406 under the open enrollment section

Life & AD&D - Sunlife

• Enrollment & Change Form - Sample
• Evidence Of Insurability Form
• Online Evidence of Insurability - Group # 90429
• Change of Beneficiary(ies) Form
• Life Conversion Kit
• Life Conversion Form
• Emergency Travel Assistance & Identity Theft Brochure
• Emergency Travel Assistance Information

Group Supplemental Retirement Account

• 2012 Base Limit Increase Memo
• 2012 Salary Reduction Agreement (with Roth option on Base Limit Contributions)
• Choosing Your Investments Brochure
• Fidelity Investments Change of Address: (via phone, PIN required) 800-868-1023, or fax a request to 877-800-5762
• Managing Your Accounts Online Brochure
• Marital Status Verification Form
• Online Enrollment Brochure
• TIAA-CREF Change of Address
• TIAA-CREF Roth Option Brochure

Long-Term Disability - Sun Life 

• Tax Designation Form
• Sun Life - Claim Form (Physician) 
• Sun Life - Claim Form (Employee) 

Employee Assistance Program (EAP) - Horizon Health

• EAP Brochure

Tuition Remission

• Employee - Paper form - Online Form
• Dependent/Spouse - Paper form - Online Form 
• Statement of Dependency
• Tax Dependency Affidavit

FACHEX

• What is FACHEX?
• FACHEX Certification Form

Adoption Assistance

• Adoption Assistance Request

Leave of Absence

• Leave Request Form
• Employee - Health Certification Form 
• Family - Health Certification Form
• Military Exigency Certification Form
• Covered Service Member Certification Form
• FMLA Employee Rights & Responsibilities Notice

Separation Summary

• TIAA-CREF Exit Summary
• 2012 Separation of Benefits