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.

2019 UPDATES & CHANGES

pdf2019 Changes & Other News

pdf2019 Open Enrollment Meeting Schedule

pdfNEW-Direct Imaging

pdfNEW-Medtipster-free

pdfNEW-MRx Empower with GoodRx

pdfNEW-Signature Care Brochure

pdfNEW-Signature Care EPO Map

 Online Enrollment for 2019

2019 Open Enrollment Forms-INTERNAL LINK-USE THIS IF YOU ARE USING A WORK COMPUTER

2019 Open Enrollment Forms-EXTERNAL LINK-USE THIS IF YOU ARE USING A PERSONAL COMPUTER

pdf2019 Open Enrollment Instructions

 2019 MEDICAL/DENTAL COVERAGE
All basic medical plan packages include health and dental coverage options-you choose the network.

pdf2019 Health Plan Summary

pdf2019 Health Plan Rates

pdf2019 Health Savings Account vs Flexible Spending Account

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
pdf2019 Vision 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

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

pdfGym Club Reimbursement Form

pdfHealthy Lifestyle Reimbursement Form

pdfEmployee Assistance Program

pdfParkview EAP FAQ

pdfManaged Care Concept-Chronic Care Program

pdfMeijer BeWell Program

pdfWellness Benefits

pdfHealthiestYou

Community Loan Center Of Northeast Indiana