Health and Benefit Forms


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NOTICE OF NONDISCRIMINATION – Click Here to download a printable PDF.

Plan Rules & Regulations:

Click Here to download a printable PDF-Health & Benefit Plan Rules and Regulations form.

Click here to download a printable PDF-Pension Plan Rules and Regulations form.

Click Here to download a printable PDF-Vacation Plan Rules and Regulations form.

Click Here to download a printable PDF-Adjustable Pension Plan Regulations form.

Summary Plan Descriptions:

Click Here to download a printable PDF-Health & Benefit Summary Plan Description form.

Click Here to download a printable PDF-Pension Summary Plan Description form.

Click Here to download a printable PDF-Vacation Summary Plan Description form.

Click Here to download a printable PDF-MM&P Adjustable Pension Plan Summary Plan Description.

Summary of Benefits and Coverage Forms (“SBC’s”):

Click Here to download a printable PDF-SBC for Actives/Non-Medicare Retirees form for 2017

Click Here to download a printable PDF-SBC for Medicare-Eligible Retirees form for 2017.

Click Here to download a printable PDF-SBC for Actives/Non-Medicare Retirees form for 2018

Click Here to download a printable PDF-SBC for Medicare-Eligible Retirees form for 2018.

CVS Caremark – Formulary Exclusions – January 1, 2017:

Click Here to download a printable PDF- CVS Caremark Formulary Exclusions effective 1/1/2017.

CVS Caremark – Formulary Exclusions – January 1, 2018:

Click Here to download a printable PDF- CVS Caremark Formulary Exclusions effective 1/1/2018.

New Cigna website information – myCigna.com – operational – October 1, 2017:

Click Here to download a printable PDF- – myCigna.com – Flyer – October 1, 2017.

Disability Insurance:

Click Here to download a printable PDF-of the Disability Insurance Brochure.

Click Here to download a printable PDF-of the Disability Insurance Proposal Request.

Click Here to download a printable PDF-of the Sample Age 40 Disability Premium.

Click Here to download a printable PDF-of the Sample Age 45 Disability Premium.

Click Here to download a printable PDF-of the Sample Age 55 Disability Premium.

Other forms:

Click Here to download a printable PDF-Affidavit for Dependent Child form.

Click Here to download a printable PDF-Affidavit for Disabled Dependent form.

Click Here to download a printable PDF-Affidavit for Dependency form.

Click Here to download a printable PDF-Agreement of Re-Payment, Assignment and Subrogation form.

Click Here to download a printable PDF-Annual Health Examination and Immunization form.

Click Here to download a printable PDF-Coordination of Benefits Information form.

Click Here to download a printable PDF-Delta Dental form.

Click Here to download a printable PDF-Statement of Claim for Weekly Disability Benefits (Employee Statement) form.

Click Here to download a printable PDF-Injury Accident Form Agreement of Re-Payment, Assignment and Subrogation form.

Click Here to download a printable PDF-Direct Member Reimbursement form (Prescription Drugs).

Click Here to download a printable PDF-Scholarship Program Brochure 2018-2019 –filing deadline November 30, 2017

Click Here to download a printable PDF-Permanent Data Form.

Click Here to download a printable PDF-CIGNA Provider Nomination Form.

Click Here to download a printable PDF-Enrollment Form for Eligible Adult Children 19-26.