View and/or print forms and information sheets below by clicking on the document title.

NOTE: Life changes (e.g. marriage, birth of a child, divorce) that create an opportunity for or require a change in coverage must be reported to the Benefits Department within 30 days of the qualifying event.

2018 UPDATES & CHANGES

pdf2018 Changes & Other News

pdfNew for 2018-HealthiestYou

pdf2018 Open Enrollment Meeting Schedule

 Online Enrollment for 2018

2018 Open Enrollment Forms-INTERNAL LINK-USE THIS IF YOU ARE USING A CITY COMPUTER

2018 Open Enrollment Forms-EXTERNAL LINK-USE THIS IF YOU ARE USING A PERSONAL COMPUTER

pdf2018 Online Open Enrollment Instructions

 2018 MEDICAL/DENTAL COVERAGE
All basic medical plan packages include health and dental coverage options-you choose the network.

pdf2018 Health Plan Summary

pdf2018 Health Plan Rates

PPO Network Information

pdf2018 Health Savings Accounts vs. Flexible Savings Accounts

pdfHSA Eligibility and Contribution Limits Table

pdfHealth Savings Account - Old National Bank

AccessingYour HSA

www.theHSA authority.com

pdfLab Services-Lab Corp

4D Pharmacy Mail Brochure - Magellan Rx

4D Pharmacy Mail Order Form - Magellan Rx

 OPTIONAL SPECIALIZED COVERAGE

VISION PLAN
pdfVision Plan Benefits Summary

Additional Materials

Contact Lens

Frames

Provider Network

Print ID Card

EPIC Discount Program

 LIFE & ACCIDENTAL DEATH/DISMEMBERMENT & SHORT AND LONG TERM DISABILITY
pdfSymetra-Beneficiary Designation Form

pdfSymetra Rate Sheet

pdfSymetra-Supplemental Life Application

pdfSymetra-Evidence of Insurability Application

pdfSymetra-Value Added Benefits

Estate Guidance
Financial Information & Resources
Legal Support
Confidential Counseling

pdfSummary of Life Benefits-PBA

pdfSummary of Life Benefits-IAFF

pdfSummary of Life Benefits-FOP

pdfSummary of Life Benefits-All Others

pdfSummary of Short Term Disability Benefits

pdfSummary of Long Term Disability Benefits

 SUPPLEMENTAL ACCIDENT & SICKNESS
pdfColonial Life-Accident Policy

pdfColonial Life - Critical Illness Policy

pdfColonial Life - Rate Sheet

Colonial Life Website

pdfColonial Life - Whole Life & Long Term Care

pdfColonial Life-Policyholder Service Guide

 FLEXIBLE SPENDING ACCOUNTS
Enrolled employees have pre-tax program options to assist them in managing their medical and/or childcare expenses.

pdfFlex Medical Debit Card Website

pdfFlex Medical Reimbursement Form

pdfFlex Childcare Reimbursement Form

 GENERAL NOTICES
A selection of medical health related City policies

pdfHIPAA Privacy Notice

pdfMemo for Spousal COB

pdfAmendment #18 Spousal COB

pdfCobra Notice

pdfFamily Medical Leave Information

pdfMedicare Part D Notice - Traditional Plan

pdfMedicare Part D Notice - High Deductible Plan

pdfExchange Notice

pdfGrandfathered Health Plan Notice

pdfMedicaid & CHIP Notice

pdfWHCRA Notice

 RETIREMENT BENEFITS
Retirement plans & savings options.

pdfPERF-at-a-Glance

pdf457 Plan-Lincoln Financial Group

pdf457 Plan-Nationwide

 WELLNESS BENEFITS

pdfGuidelines for Healthly Lifestyle Benefit

pdf2018 Gym Club Reimbursement Form

pdfHealthy Lifestyle Reimbursement Form

pdfEmployee Assistance Program

pdfParkview EAP FAQ

pdfManaged Care Concept-Chronic Care Program

pdfMeijer BeWell Program

pdf2018 Wellness Benefits

pdfHealthiestYou

Community Loan Center Of Northeast Indiana