Benefits Forms

Active Employee Plans

Medical Plans

• Kaiser Benefits Summary (PDF)
• United HealthCare HMO Performance Network Guide (PDF)
• United HealthCare HMO Performance Network 1 Summary (PDF)
• United HealthCare HMO Performance Network 2 Summary (PDF)
• United HealthCare HMO Performance Network 3 Summary (PDF)
• United HealthCare Alliance HMO Benefit Summary (PDF)
• VEBA Medical Enrollment/Change Form (ALL MEDICAL PLANS) (PDF)
• How to Select Your Doctor - United HealthCare (PDF)

Chiropractic/Acupuncture Plan

• American Specialty Chiropractic & Acupuncture Coverage (PDF)

Dental Plans

• Delta Dental Benefits Summary (PDF)
• Delta Dental Enrollment Form (PDF)
• Delta Dental Enrollment Kit (PDF)

Employee Assistance Plan (EAP)

• VEBA EAP Benefits Summary (PDF)
• VEBA EAP Brochure (PDF)
• Managed Health Network (MHN) EAP Brochure (for those not enrolled in a medical plan) (PDF)

Vision Plan

• Medical Eye Services (MES) Benefits Summary (PDF)
• MES Enrollment/Change Form (PDF)

Domestic Partner

• SWC Domestic Partnership Affidavit (PDF)

Flexible Spending

• Flexible Spending Reimbursement Voucher (PDF)
• Dependent Day Care Reimbursement Voucher (PDF)
• AFA Direct Deposit Form (PDF)

General Benefit Forms

• SWC Payment Vouchers (PDF)
• Universal Cancellation Form (all plans except for medical, dental and vision) (PDF)
• Best Doctors Experts Flyer (PDF)

Insurance Waivers

• Classified Waiver Form (PDF)
• Faculty Waiver Form (PDF)

Express Scripts (MEDCO) Prescriptions

• MEDCO Prescription Overview (PDF)
• MEDCO Mail Order Form (PDF)

Life Insurance

• MetLife Beneficiary Designation Change Form (PDF)
• Prudential Beneficiary Designation Change Form (PDF)

Payroll Deductions

• Payroll Deductions (PDF)

Tax Sheltered Annuities 403(b)/457

• FBC Salary Reduction Agreement (PDF)