Benefit Forms and Plan Documents

Matching Gifts Program

Please see Matching Gifts page. 

Healthcare and Related Forms

 

Alliant Insurance Services Administrators, Inc. (AIS) ACH Bank Transfer Form (Medical Prem./Medicare Reimb.) (pdf) Download
Cigna Medical Claim Form (pdf) Download
Cigna Prescription Drugs Claim Form (pdf) Download
Cigna Vision Claim Form (pdf) Download
Cigna Dental Claim Form (pdf) Download
Healthcare Continuity of Care Request Form (CIGNA) (pdf) Download

Notices and Policies

  

Continuation of Coverage for Dependents Until Age 31 (pdf) Download
HIPAA Privacy Practices Policy (pdf) Download
Summary Annual Report - Health & Welfare Plan 01/01-12/31/2025 (pdf) Download

Plan Documents and Summaries

 

Cigna Summary of Benefits & Coverage (pdf) Download
DPPO (Dental) Summary (pdf) Download
DHMO (Dental) Flyer (pdf) Download
Cigna Vision Summary (pdf) Download
Cigna Summary Plan Description (SPD) (pdf) Download
Cigna Multi-State Medical Rider (pdf) Download
Cigna Multi-State Vision Rider (pdf) Download
Cigna Dental Plan Document (DHMO) (pdf) Download
Cigna DHMO Multi-State Rider (pdf) Download
Cigna Dental Plan Document (DPPO) (pdf) Download
Cigna DPPO Mulit-State Rider (pdf) Download

Domestic Partnerships

 

 

Affidavit of Domestic Partnership (pdf) Download
Domestic Partner’s Request for Dependent Coverage (pdf) Download
Certification of IRS Tax-Qualified Dependents (pdf) Download