Summary of Benefits
		Election of Coverage and Eligibility Provisions
		Comprehensive Medical Benefits
		Income Protection Benefit
		Dental Benefit
		Dental Schedule of Benefits
		Prescription Drug Benefit
		Vision Benefit
		Life Insurance & AD&D Benefit
		General Exclusions and Limitations

		Summary of Benefits
		Election of Coverage and Eligibility Provisions
		Comprehensive Medical Benefits
		Prescription Drug Benefit
		General Exclusions and Limitations

		How to File a Claim
		When to Call Us
		Request an ID Card
		Continuation of Coverage (COBRA)
		Claim Appeal Procedure
		Coordination of Benefits
		Privacy Practices
		Health Benefits Plan Claim Procedures
		Summary of the Cafeteria Plan
		Forms & Publications

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HEALTH FORMS

Some plans do not include every benefit mentioned. Refer to your plan booklet to verify which benefits are included in your plan.

Authorization for Release of
Personal Health Information (all Plans except Plan B5 and Plan 7)

Authorization for Release of
Personal Health Information (Plan B5 or Plan 7)

Autorización para la divulgación de información médica personal

Dependent Coverage Registration Form

Designation of Beneficiary for the Death Benefit

Health Claim Form

Dental Claim Form

Vision Claim Form

Continuing Income Protection Claim Form

Application for Plan M

Authorization Agreement for Electronic
Transfer of Payments for Plan M

Authorization Agreement for Electronic
Transfer of Payments for COBRA

Dental Schedule of Benefits

Health Plan Document

Notice of Prescription Drug Creditable Coverage under Medicare

Privacy Practices

Glossary for the Summary of Benefits and Coverage (SBC)

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(Updated 01/15/13)