For Employees

• Forms and Documents

• Benefits Information
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Forms and Documents

• *** Wellness Program Health Screenings ***
  • WellFit Advantage Personal Health Profile Link
  • Personal Health Profile Instructions
  • Instrucciones de Perfíl Personal de Salud

• *** Open Enrollment Information ***
  • Employee Health Enrollment Application
  • 2012 Medical and Dental Waiver of Coverage
  • 2012 Renuncia de Cobertura Médica y Dental
  • Lumenos with HSA and Rewards Plan Summary
  • Resumen del plan Lumenos con HSA y recompensas
  • HSA Payroll Deduction Form
  • Forma de Deducción de Nómina HSA
  • Anthem KeyCare 500 and Prescription Drug Plan Summary
  • Anthem KeyCare 500 y Resumen del Plan de Medicamentos Recetados
  • Delta Dental Group Enrollment Application
  • Delta Dental Aplicación de Envolvimiento
  • Delta Dental PPO Plus Premier Summary
  • Delta Dental Resumen del PPO más PRemier
  • 2012 Employee Benefits Annual Notification Package

• Payroll
  • Direct Deposit Form with Instructions
  • Forma de Deposito Directo con Instrucciones
  • Change of Address Form
  • Monthly Mileage Report

• Insurance (Health / Dental)
  • Anthem Employee Health Enrollment Application
  • Delta Dental Enrollment / Change Form
  • Anthem List of Authorized Representatives of Group Health Plan
  • Anthem Member Change Form
  • Health and Dental Waive Form
  • Anthem Benefit Guide

• Health Savings Account
  • HSA Website

• Life and Short Term Disability
  • Standard Hourly Life and Short Term Disability Enrollment Form
  • Standard Salary Life Enrollment Form
  • Standard Medical History Statement Form
  • Standard Beneficiary Designation/Change Form
  • Standard Disability Claims Form

• 401(k)
  • 401(k) Designation of Beneficiary Form
  • 401(k) Participant Change Form
  • 401(k) Profit Sharing Plan Rollover Contribution Form
  • 401(k) Profit Sharing Plan Enrollment Form

• Other Useful Links
  • Generic Prescriptions for $9.99 at Giant Pharmacy
  • Generic Prescriptions for $4 (30 Day) and $10 (90 Day) at Kroger Pharmacy
  • Generic Prescriptions for $4 (30 Day) and $10 (90 Day) at Target Pharmacy
  • Generic Prescriptions for $4 (30 Day) and $10 (90 Day) at Walmart Pharmacy