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Plan Documents

Our team of professionals will be there to assist you in bringing this exceptional benefit to your members.

Participant Forms

Participant Data Form
Premium Reimbursement Claim Form
Medical Expense Reimbursement
Claim Form

Individual Account Management

Performance Reports
Investment Selection Packet

April 2022

Investment Selection Form
Conversion Election Information Packet

(Rev. 2019 03)

Conversion Chart

Effective March 1, 2022

Conversion Chart

Effective March 1, 2019

Conversion Chart

Effective March 1, 2016

Conversion Chart

Effective May 31, 2013

Notices

2023 Annual Premium Verification Notice & Claim Form
Summary Annual Report
Summary of Material Modifications Discussing Changes to Monthly Verification of Premiums

Effective January 1, 2022

Summary of Material Modifications
Proof of Payment of Premium

August 18, 2022

Summary of Material Modifications
Retiree Contributions to Surviving Spouses

November 14, 2022

COBRA General Notice
HIPAA Notice of Privacy Practices

Plan Documents

Summary Plan Description

Effective March 1, 2021

Restated Plan

Effective March 1, 2021

Plan Amendment No. 12
Plan Amendment No. 13
Plan Amendment No. 14
Publication 502 - Medical and Dental Expenses

IRS Publications

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