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Benefit Forms and Information
Consolidated Appropriations Act, 2021 (CAA)
Annual Notices
Medical Insurance
- Medical Plan Designs
- PreferredOne_BenefitHub_Members (PDF)
- $500 Deductible Plan SBC (PDF)
- $750 Deductible Plan SBC (PDF)
- Health Plan $500 SPD (PDF)
- Health Plan $750 SPD (PDF)
- Health Plan Preventative Care Services Schedule (PDF)
- PreferredOne Administrative Services (PAS)-MY ACCOUNT (PDF)
- Insurance Enrollment-Declination Form
Dental Insurance (Use Insurance Enrollment/Declination Form)
- Dental Plan Designs
- Dental Basic Plan SBC 2019 (PDF)
- Dental Buy Up Plan SBC 2019 (PDF)
- Dental Basic Plan SPD 2019 (PDF)
- Dental Buy Up Plan SPD 2019 (PDF)
- Dental Buy Up Plan - Enhanced Benefits Program (PDF)
- Dental - Child Oral Health (PDF)
- Dental - Oral Health Facts (PDF)
- Dental My Account - Delta Dental Resource Guide (PDF)
Vision Insurance (Use Insurance Enrollment/Declination Form)
Deferred Compensation
Legal Services
Flexible Spending
- Flex - My Company Plan
- Flex Spending Enrollment Form
- Flex Enrollment Guide Form EBC (PDF)
- Flex - Claims Substantiation (PDF)
- Flex Benefits Debit Card - EBC (PDF)
- Flex Eligible Expenses (PDF)
- Flex Eligible Expenses - Dependent Care (PDF)
- Flex Employee Planning Worksheet (PDF)
- Flex - MY ACCOUNT Quick Reference Guide (PDF)
- Flex Paper Claim Form (PDF)
- Flex - Submit a Claim Online Guide (PDF)
- Flex SPD (PDF)
- FLEX Mobile Account-Quick Reference Guide (PDF)
- FLEX Mobile Account (PDF)
Life Insurance
- MNL Change of Beneficiary Form- revised 10.2016 (PDF)
- MNL Change of Beneficiary Form- revised 10.2016 FAQs (PDF)
- MNL Enrollment Form 1.2020 (PDF)
- MNL EOI Evidence of Insurability form 07.01.14 (PDF)
- MNL EOI Helpful Hints (PDF)
- MNL Supplemental Ins Rates (PDF)
- MNL Certificate-Long Term Disability-Administrators (PDF)
- MNL Certificate-Group Term Life 7.1.2019 (PDF)
- MNL Certificate-All Eligible EEs-Voluntary Supplemental Life (PDF)
- MNL Voluntary Supplemental Life Ins - FAQs (PDF)