

If you don't see a form or document here, please contact us.
Medical HMOs
Medical PPO & HSA
Dental HMO
Dental PPO
Vision
Chiropractic
Life Insurance
Continuity of Coverage
Student Status Form
Declination of Coverage
PacifiCare Change
PacifiCare COBRA
Prescription Mail Order

PacifiCare HMO (High) - Schedule of Benefits Prescription Benefits Mental Health
PacifiCare HMO (Low) - Schedule of Benefits Mental Health Prescription
Benefits
United Health Care PPO - Schedule of Benefits Prescription Benefits Certificate of Coverage (Booklet)
United Health Care HSA - Schedule of Benefits Prescription Benefits Certificate of Coverage (Booklet)
Dental HMO - Schedule of Benefits
Dental PPO - Schedule of Benefits
Vision - Schedule of Benefits
Chiropractic - Schedule of Benefits Booklet - Chiropractic & Acupunture Booklet - Chiropractic Only
Section 125 - Enrollment Form Enrollment Packet
Claim Form (Reimbursement Request)
Day Care Provider Receipt
Eligible Expenses
OTC Flyer
Life - $15,000 $25,000 $50,000
Summary Plan Description
Trust Agreement
Amendment 1
Amendment 2
Amendment 3
Amendment 4
Amendment 5
Cafeteria Plan Plan Document
Domestic Partner Coverage Information
Fringe Benefit Contribution Info
Payroll Record Review and Dispute Resolution
Qualified Medical Child Support Order Procedures