Benefits & Insurance Forms

Change of Status forms must be completed within 30 days of a life changing event (ie. birth of a child / marriage / divorce)

OPEN ENROLLMENT -  2011

Mandatory HVS Open Enrollment Forms

• Required Teacher Open Enrollment Form
• Required All Other Groups Open Enrollment Form
  
  

Benefits Open Enrollment Newsletter

Benefits for life

Benefits for life Brochure-Optional Coverage

Benefits for Life-Open Enrollment Flyer

IMPORTANT RIGHTS AND NOTICES - 2010
      HSA Reimbursement for Expenses for Dependents

Flexible Spending Accounts
     Important Information Regarding Flexible Spending Accounts
     Flexible Spending Account Election Form

Opt Out--Cash in Lieu of Health Form (Teachers Only)

Employer Sponsored Health Plans  

MESSA Forms & information

• MESSA Open Enrollment Information
• Member Application for MESSA Benefits-New Enrollee
• MESSA Member Change Form--Change in Marital Status, Dependents, or Personal Information--Currently Enrolled
• MESSA Gives You Options
• MESSA Choices PPO $300/600
• Understanding Your Deductible  (Teachers Only)
• MESSA Adult Immunization Rider (Teachers Only)
• MESSA Saver RX (Teachers Only)
• Delta Dental (Teachers Only)
• VSP2 Vision Plan (Teachers Only)
  VSP Panel Benefits
  VSP Non Panel Benefits

other health plans

       
     Priority Health PPO/HSA
     Priority Health Website
     Priority Health Benefit Summary
     Priority Health Enrollment Form
     Priority Health and Flagstar HSA Directions
    

     HAP Health Plans

     HAP Benefit Summary (HVESP and HVPEA)

     HAP Benefit Summary (HVSSP)

    
Dental - MetLife (All groups except teachers)

• Dental ID Card
• Dental Enrollment Form
• Dental Claim Form
  
• MET Life - HVESP
• MET Life - HVSSP
• MET Life - AFSCME
• MET Life - HVCEF
• MET Life - HVAA
• MET Life - HVSMC
• MET Life - HVCS 

 To see a list of providers, click here

Vision - NVA, National Vision Administrators (All groups except teachers)

Vision Enrollment Form
Vision Claim Reimbursement Form
NVA - Option 1 - AFSCME
NVA - Option 2 - HVSSP
NVA - Option 3 - All Other Groups 

To see a list of providers, click here

Schedule of Benefits-vision

• AFSCME - Option 1
• HVSSP - Option 2
• All Other Vision Eligible Groups - Option 3

Section 125 Flex Plan-Next Generation Enrollment

• 
  Important Information Regarding Flexible Spending Accounts
  Flexible Spending Account Election Form
  Changes to over-the-counter eligibility for Flexible Spending Accounts
  New IRS Requirements Effective 9/1/09 Affecting Benefits MasterCard
  Flex Spending Account Access Directions
  Spending Plan and Debit Information 
  Flex Spending Accounts FAQ
  Direct Deposit Authorization Form
  Healthcare Flexible Spending Account Reimbursement Form
  Dependent Care FSA Reimbursement Form 

other benefits

TEAM EMPLOYEE ASSISTANCE PROGRAM
Web Poster Page One
Web Poster Page Two

Benefits for Life - 100% Employee Paid
Trustmark Voluntary Benefit Solutions, Inc.

Corporate Office
Phone: 1-800-918-8877, Option 6
e-mail: customeradvocate@trustmarkins.com

Billing Representative - Moriah Extence
Phone: 1-262-240-5412
e-mail: moriah.extence@trustmarkins.com

Contact the Billing Representative for any questions you may have regarding your payment.

Optional Life Insurance
Mutual of Omaha Customer Service
Phone: 1-800-283-9591

All groups except teachers

Life Insurance Forms

RELIANCE STANDARD-ALL GROUPS EXCEPT TEACHERS

Huron Valley Beneficiary Form

Voluntary Supplemental Term Life Enrollment Form

Supplemental Term Life General Information