Benefits Forms and Publications

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Important Resources
Annual Security Report (2012)
HUC-JIR Personnel Handbook (PDF format)

2012-2013
Web Prescription Order Form
Anthem Benefit Booklet
Medical Coverage Comparison Summary Base vs Buy Up vs HSA
2012 Open Enrollment - Power Point Presentation for OE Meeting
CDB FSA brochure
Employee All Elections Form Rev 8-11 - Short Plan Year
FSA Claim Form
How FSA Card Works, How to file Claim
VSP Enrollment Form with Dependent Data
VSP Vision Benefits Summary.pdf

2011-2012
Open Enrollment Recording (MP3)
Open Enrollment PowerPoint Presentation
Flexible Spending Account Brochure
FSA/TERA Enrollment Form
FSA/TERA Direct Deposit Form
Anthem Enrollment Application
Anthem Comparison Summary - Base vs Buy Up vs HSA

Older
Anthem Base Plan - Summary Plan Description
Anthem Anthem Buy Up Plan - Summary Plan Description (PDF format)
Anthem - CA Out of Network Claim Form (PDF format)
Anthem Enrollment Form Instructions (PDF format)
Anthem Preventive Care Summary (PDF format)
Fidelity 403(b) Defined Contribution Beneficiary Designation Form (PDF format)
Fidelity 403(b) Defined Contribution Salary Reduction Agreement (PDF format)
Fidelity Investment Options (PDF format)
Fidelity Supplemental 403(b) New Account Application (PDF format)
Fidelity Rollover Form (PDF format)
Fidelity Supplemental 403(b) Salary Reduction Agreement (PDF format)
FSA Claim Form (PDF format)
Guardian Enrollment Form (PDF format)
Medical Claim Form (PDF format)
New York Out-of-Network Medical Claim Form (PDF format)
Prescription Drug Claim Form (PDF format)
Reliance Life Insurance Beneficiary Form (PDF format)
TERA Claim Form (PDF format)

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