• Cigna Health Plan Book

• Delta Dental Book

• Standard Basic Life Guide

• Standard Basic Life Insurance Certificate

• Flexible Benefits Book (updated 1/1/2020)

• 2021 Summary Benefits Comparison (SBC) 900 Deductible

• 2021 Summary Benefits Comparison (SBC) 2000 Deductible

• 2021 Summary Benefits Comparison (SBC) 4000 Deductible

• 2021 Summary Benefits Comparison (SBC) High Deductible Health Plan (HDHP)

VOLUNTARY BENEFIT INFORMATION

• Voluntary Benefits Brochure (updated 2/2021)

• Disability - Short/Long Term Disability Book (updated 10/2020)

• Vision - VSP Vision Benefits Flyer (updated 2019)

• Life - Standard Voluntary Life Insurance Guide

• Life - Standard Voluntary Life Certificate

• Ambulance - MASA Member Service Agreement

PREMIUM RATES & CALCULATORS

• January 2021 Active & Cobra Rates (Health, dental)

• 2021 Life Insurance Premium Rates

• Standard Voluntary Life Rate Grid

• Disability Premium Calculator

• Voluntary Benefits Brochure (Vision Rates)

• Manual Rate Calculator Jan 2021 (Full-time)

• Manual Rate Calculator Jan 2021 (Awec/TP01)

• Manual Rate Calculator Jan 2021 (Part-time)

• January 2021 Rate Calculator Full-time (DOWNLOAD, open in Excel)

• January 2021 Rate Calculator (AWEC/TP01) DOWNLOAD, open in Excel)

• January 2021 Rate Calculator Part Time (DOWNLOAD, open in Excel)

APPLICATION & ENROLLMENT

• Active Benefits Application 2021 (Health, Dental and Life)

• Voluntary Benefits Application (Vision & Disability)

• Voluntary Life Application ( 2021)

• MASA Ambulance Application (updated 2/2021)

• 2021 Flexible Benefits Election Form

• Flex Benefits Change Form (used for mid year changes)

• Link to Genworth site When prompted enter: Group Name: statewy Access code: groupltc

• 2021 Health Savings Account Election Form

• Long Term Disability Application Link

OTHER FORMS

• Medical Reimbursement & Dependent Care Claim Form (Updated 4/25/2017)

  • • Flex deadline is every Friday. Reimbursements are payable the the 2nd Thursday after deadline.

• Qualifying Event Matrix What benefits can be changed based on a qualifying event.

• MedImpact Direct Rx Mail Order Form For use on prescriptions that did not go through a retail pharmacy.

• MedImpact Claim Form Used for manual submission of prescription reimbursement.

• Delta Dental Claim Form Used to send your claim to Delta Dental when your provider is non-participating.

• Direct Payment Authorization

• Vision Out of Network Reimbursement Claim Form

• Short Term Disability Claim Form The Standard Company 1-800-368-2859

• Long Term Disability Claim Form The Standard Company 1-800-368-1135

• Cigna Claim Form Used to send medical claims to Cigna.

• Evidence of Insurability for Standard Life Insurance

• HIPAA Privacy Authorization Form

PRIOR YEARS INFORMATION