All of our forms are in PDF format, so you will need to download and install Adobe Acrobat® if you have not already done so.

• Employee Benefit Plans Information
• 2016 Employee Benefits Handbook
• 2016 Healthcare Payroll Deductions

Healthcare Notices

• Market Exchange Notice – 2014
• Medicare Part D – 2016 COPAY Medical Plan
• Medicare Part D – 2016 CDHP Medical Plan
• Medicare Part D – 2015 COPAY Medical Plan
• Medicare Part D – 2015 CDHP Medical Plan

Medical

• COPAY Medical Plan Coverage Summary
• CDHP (Consumer Driven Plan) Medical Plan Summary
• Annual Physical Discount Form (PCP) – 2016
• Annual Physical Discount Form – 2015
• Rx Mail Order Form
• Medical Claim Form
• HIPAA Release
• Humana Website

Vision

• EyeMed Out of Network Claim Form

Health Savings Account (HSA)

• HSA Enrollment Form
• Park National Locations
• Horan Video Link – CDP / HSA  
• Wellmark BCBS HSA Video Link  

Flexible Spending Account (FSA)

• Direct Deposit Form
• FSA Reimbursement Request Form
• FSA Debit Card Substantiation Form
• FSA – Qualifying Event Change Form

Life, LTD & STD Insurance

• Life Insurance Beneficiary Form
• Evidence of Insurability Form (EOI) – 2015
• Envidence of Insurability Instructions – 2015
• Waiver of Premiums – Life Insurance – 2015
• Disability Claim Form / Physicians Statement – 2015
• Voluntary STD-LTD – Cancellation Form
• Voluntary STD-LTD Disability Claim Form
• Life Insurance Policy – 2015
• Long Term Disability Policy – 2015