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.

2022 UPDATES & CHANGES

NEW-2022 Open Enrollment Benefits Video

pdf2022 Changes and Other News

pdfNEW-Beam Dental Benefits Summary

pdfNEW-Beam FAQs

pdfNEW-HRA FAQ

pdfNEW-HRA Reimbursement Form

  Online Enrollment for 2022

     2022 Open Enrollment Forms-Internal Link

     2022 Open Enrollment Forms-External Link

 2022 MEDICAL/DENTAL COVERAGE
All basic medical plan packages include health and dental coverage options.

pdf$1200 Deductible Plan Summary

pdf$3400 Deductible Plan Summary

pdf2022 Health Plan Rates

pdfSignature Care Brochure

pdfSignature Care EPO Map

pdfDirect Imaging

pdfHealthiestYou

pdf2022 Health Savings Account vs Flexible Spending Account

pdfHealth Savings Account-Old National Bank

AccessingYour HSA

www.theHSA authority.com

pdfLab Services-Lab Corp

Magellan Rx Mail Brochure

Magellan Rx Mail Order Form

pdfMedtipster-free

pdfMRx Mobile App Client

pdfMagellan Rx Member Website Guide

pdfMRx Select Savings

 OPTIONAL SPECIALIZED COVERAGE

VISION PLAN

pdfVision Benefit 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

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

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 Healthy Lifestyle Benefit

pdfGym Club Reimbursement Form

pdfHealthy Lifestyle Reimbursement Form

pdfEmployee Assistance Program

pdfParkview EAP FAQ

pdfManaged Care Concept-Chronic Care Program

pdfManaged Care Concept-Healthy Track

pdfDaavlin Home Phototherapy Benefit

pdfWellness Benefits

Community Loan Center Of Northeast Indiana