Benefit Forms and Information

Consolidated Appropriations Act, 2021 (CAA)

Transparency in Coverage - Machine Readable Files

Annual Notices

  1. NOTICE-4 in 1 Annual Health Plan Notices
  2. NOTICE - MHPAEA Exemption Notice
  3. NOTICE - CHIP Notice - Iowa
  4. NOTICE - Marketplace Coverage Options
  5. NOTICE - Medicare Part D Creditable Coverage Disclosure
  6. NOTICE - Privacy Notice for Health Care Plans - HIPAA

Medical Insurance

  1. Medical Plan Designs
  2. PreferredOne_BenefitHub_Members (PDF)
  3. $500 Deductible Plan SBC (PDF)
  4. $750 Deductible Plan SBC (PDF)
  5. Health Plan $500 SPD (PDF)
  6. Health Plan $750 SPD (PDF)
  7. Health Plan Preventative Care Services Schedule (PDF)
  8. PreferredOne Administrative Services (PAS)-MY ACCOUNT (PDF)
  9. Insurance Enrollment-Declination Form

Dental Insurance (Use Insurance Enrollment/Declination Form)

  1. Dental Plan Designs
  2. Dental Basic Plan SBC 2019 (PDF)
  3. Dental Buy Up Plan SBC 2019 (PDF)
  4. Dental Basic Plan SPD 2019 (PDF)
  5. Dental Buy Up Plan SPD 2019 (PDF)
  6. Dental Buy Up Plan - Enhanced Benefits Program (PDF)
  7. Dental - Child Oral Health (PDF)
  8. Dental - Oral Health Facts (PDF)
  9. Dental My Account - Delta Dental Resource Guide (PDF)

Vision Insurance (Use Insurance Enrollment/Declination Form)

  1. Vision Plan Design
  2. Vision (Avesis) Benefits Flyer (PDF)
  3. Vision (Avesis) Mobile App (PDF)
  4. Vision (Avesis) L2 Option (PDF)

Deferred Compensation

  1. Nationwide Flyer
  2. Nationwide Enrollment and Payroll Authorization Forms (PDF)
  3. Nationwide Retirement-457 Brochure (PDF)

Legal Services

  1. Legal Shield Flyer- Black Hawk County (PDF)
  2. Legal Shield_Benefit Election and Payroll Authorization Form (PDF)
  3. Legal Shield_ID Shield_Quick Start Guide_after enrolled (PDF)
  4. Legal Shield_Quick Start Guide_after enrolled (PDF)

Flexible Spending

  1. Flex - My Company Plan
  2. Flex Spending Enrollment Form
  3. Flex Enrollment Guide Form EBC (PDF)
  4. Flex - Claims Substantiation (PDF)
  5. Flex Benefits Debit Card - EBC (PDF)
  6. Flex Eligible Expenses (PDF)
  7. Flex Eligible Expenses - Dependent Care (PDF)
  8. Flex Employee Planning Worksheet (PDF)
  9. Flex - MY ACCOUNT Quick Reference Guide (PDF)
  10. Flex Paper Claim Form (PDF)
  11. Flex - Submit a Claim Online Guide (PDF)
  12. Flex SPD (PDF)
  13. FLEX Mobile Account-Quick Reference Guide (PDF)
  14. FLEX Mobile Account (PDF)

Life Insurance

  1. MNL Change of Beneficiary Form- revised 10.2016 (PDF)
  2. MNL Change of Beneficiary Form- revised 10.2016 FAQs (PDF)
  3. MNL Enrollment Form 1.2020 (PDF)
  4. MNL EOI Evidence of Insurability form 07.01.14 (PDF)
  5. MNL EOI Helpful Hints (PDF)
  6. MNL Supplemental Ins Rates (PDF)
  7. MNL Certificate-Long Term Disability-Administrators (PDF)
  8. MNL Certificate-Group Term Life 7.1.2019 (PDF)
  9. MNL Certificate-All Eligible EEs-Voluntary Supplemental Life (PDF)
  10. MNL Voluntary Supplemental Life Ins - FAQs (PDF)