Documents
- Accident or Injury Report Form
- COVID-19 Test Kit Claim Form
- How, When and Where Injury Form
- Loss of Time ACH Authorization Form
- Loss of Time (Short Term Disability) Claim Form
- OptumRx Mail Order Prescription Drug Form
- Reimbursement Agreement & Attorney Agreement — Work-Related Injury
- Reimburse Agreement — Non Work-Related Injury
- Reimbursement Prescription Form
- Address Change Form
- Enrollment Form
- HIPAA Authorization for Disclosure of Protected Health Information
- Reciprocity Transfer Authorization Form
- Retiree Authorization for Direct Payment
- Spousal Employment Form
- Termination of Coverage Affidavit for Adult Dependent
- Termination of Coverage Affidavit for Minor Dependent
- Prefunding Retiree Benefits Brochure
- Summary of Benefits – January 1, 2023
- Summary of Benefits – January 1, 2020
- Summary of Benefits and Coverage – June 1, 2023
- Summary Plan Description SPD – (as published on January 1, 2020)
- Health Reimbursement Account (HRA) Brochure – 2020 Edition
- Summary of Material Modifications – COVID19 End and Telehealth Continue
- Summary of Material Modifications – Various Benefit Changes – April 2023
- Summary of Material Modifications – Death Benefit Beneficiary – April 2022
- Summary of Material Modifications – Various Benefit Changes – April 2021
- Summary of Material Modifications – COVID19 and Telehealth Coverage – March 2020
- Amendment No. 1 – COVID19 Coverage
- Amendment No. 2 – Suspension of Deadlines for COVID19
- Amendment No. 3 – Dental PPE Coverage for COVID19
- Amendment No. 4 – COB for ESRD and USERRA
- Amendment No. 5 – Retiree Opt Out Benefits
- Amendment No. 6 – Extension of Deadlines Modification
- Amendment No. 7 – COBRA Subsidy
- Amendment No. 8 – Vision Benefit
- Amendment No. 9 – Beneficiary and Maternity LOT
- Amendment No. 10 – COVID OTC Tests
- Amendment No. 11 – Various Benefits
- Amendment No. 12 – Organ Transplant Rejection
- Amendment No. 13 – Infertility and Routine Annual Physicals
- Amendment No. 14 – End of COVID19 Benefits