If you don't see a form or document here, please contact us.

 

Enrollment Forms

Medical HMOs
Medical PPO & HSA
Dental HMO
Dental PPO
Vision
Chiropractic
Life Insurance

Other Forms

Continuity of Coverage
Student Status Form
Declination of Coverage
PacifiCare Change
PacifiCare COBRA
Prescription Mail Order

 

 

Plan Documents

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

 

Employer Documents

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