Staff – Benefit Plans
Employee Benefits Presentation at FHS (December 2019) – View
- CMS Medicare Part D Notification
- COBRA General Notice
- Health Insurance Election Form
- Spousal Eligibility Form
- Spousal Eligibility Form – Custodian/Maintenance ONLY
- Old Fort Bank HSA Account Set-Up
- HSA Qualified Medical Expenses
- UMR Plan Summaries
- EBSO (dental/vision) Policy Booklet
- EBSO (dental/vision) Plan Summary
- EBSO Dental Claim Form
- EBSO Vision Claim Form
- Minnesota Life Insurance Certificate
- Minnesota Life Enrollment Form (Employee/Spouse/Children)
- Minnesota Life Beneficiary Designation/Change
- Minnesota Life Evidence of Insurability (this form is required for all supplemental coverage except the 10K available for children)
- all supplemental coverage (Employee or Spouse) requested after June 7, 2013.
- American Fidelity – Flex Spending – Direct Deposit Form
- American Fidelity Dependent Day Care Filing Claims, Instructions and Forms
- American Fidelity Pregnancy Filing Claims, Instructions and Forms
- American Fidelity – Flex Spending – Filing Claims, Instruction, and Forms
- American Fidelity Disability Filing Claims, Instruction and Forms
- Dept. of Labor Exchange Model Notice – posted 8/9/17
- Important Legal Notices
- Wellness Program Notice
- ICWS Wellness Physician Form
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