Benefit Forms

Certified Staff Health Insurance Enrollment Form 2022-2023

CERTIFIEDPROF202220232.pdf 225.62 KB (Last Modified on July 6, 2022)

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Certified Staff Waiver Form 2022-2023

WaiverCertified20222023.pdf 217.33 KB (Last Modified on August 9, 2022)

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Classified Staff Health Insurance Enrollment Form (21 pays) 2022-2023

SupportStaff21pays202220232.pdf 224.63 KB (Last Modified on July 6, 2022)

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Classified Staff Health insurance Enrollment Form (26 Pays) 2022-2023

SupportStaffANDConfEx26pays202220232.pdf 224.59 KB (Last Modified on July 6, 2022)

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Classified Staff Waiver Form 2022-2023

WaiverSupport20220223.pdf 232.74 KB (Last Modified on August 9, 2022)

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COBRA Continuation of Coverage Healthcare Election Form 2022-2023

CobraElectionForm202220232.pdf 113.09 KB (Last Modified on July 6, 2022)

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COBRA Member Handout 2022-2023

COBRA Member Handout.pdf 316.08 KB (Last Modified on July 6, 2022)

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Life Insurance Beneficiary Form

BeneficiaryDesignationFormSept20212.pdf 184.57 KB (Last Modified on July 6, 2022)

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Long Term Disability Information and Enrollment Form

UNUM_LTDHighlightandEnrollment2.pdf 578.83 KB (Last Modified on July 6, 2022)

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Medicare Credible Coverage

Creditable Coverage Disclosure Notice_2023.pdf 220.19 KB (Last Modified on October 5, 2022)

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Claim Forms

Employees who wish to receive matching payments for the wellness initiatives available through DVHT should complete the steps outlined in the DVHT Wellness Benefits Overview and then submit proof of payment/reimbursement from DVHT by uploading the needed documentation in this form: Delaware Valley Health Trust (DVHT) Wellness Initiatives Matching Google Form

United Group Flexible Spending Claim Form

Updated FSA Claim Form.pdf 598.83 KB (Last Modified on October 4, 2022)

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Flexible Spending Account Benefits

Flexible Spending Account Benefits.pdf 273.48 KB (Last Modified on July 6, 2022)

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Optimed Flexible Spending Plan Consumer Portal Quick Start Guide

Optimed Consumer Portal Quick Start Guide.pdf 307.65 KB (Last Modified on July 6, 2022)

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United Concordia Claim Form

United Concordia Claim Form2.pdf 819.63 KB (Last Modified on July 6, 2022)

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Delta Dental Claim Form

Delta Dental Claim Form2.pdf 152.07 KB (Last Modified on July 6, 2022)

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Long Term Disability Claim Information

UNUMDisabilityClaimInformation.pdf 189.88 KB (Last Modified on July 6, 2022)

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Long Term Disability Claim Form

LTD Claim Form-Unum.pdf 1.06 MB (Last Modified on September 14, 2022)

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Open Choice® - PPO $10/$20

SBC.PPO.10.20.pdf 468.74 KB (Last Modified on November 1, 2022)

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Open Choice® - PPO $20/$20

SBC.20.20.pdf 465.91 KB (Last Modified on November 1, 2022)

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Open Choice® - PPO $20/$40

SBC.20.40.pdf 469.14 KB (Last Modified on November 1, 2022)

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Open Choice® - PPO $10/$20 RX $15/$30/$50

SBC.PPO.10.20.RX.15.30.50.pdf 469.62 KB (Last Modified on November 1, 2022)

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Open Choice® - PPO $20/$20 RX $15/$30/$50

SBC.20.20.15.30.50.pdf 469.8 KB (Last Modified on November 1, 2022)

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Open Choice® - PPO $20/$40 RX $15/$30/$50

SBC.20.40.15.30.50.pdf 470.18 KB (Last Modified on November 1, 2022)

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QPOS® - QPOS $30/$40

SBC.QPOS.30.40.pdf 467.61 KB (Last Modified on November 1, 2022)

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QPOS® - QPOS $30/$40 RX $15/$30/$50

SBC.QPOS.30.40.RX.15.30.50.pdf 471.01 KB (Last Modified on November 1, 2022)

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Standalone Pharmacy – RX $15/$30/$50

SBC.RX.15.30.50.Standalone.pdf 463.42 KB (Last Modified on November 1, 2022)

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