Benefits - By Plan



  • Affidavit for Insurance Purposes
    Affidavit for Insurance Purposes

    Complete and submit with your health insurance application if your covered family member is not a U.S. citizen and does not have a Social Security number.

  • HSA Beneficiary Form
    HSA Beneficiary Form

    Complete and submit to the HSA plan administrator to name who you would like to receive benefits payable upon your death.

  • HSA Enrollment Form
    HSA Enrollment Form

    If you are enrolling in the HDHP or Access HDHP, you must also be eligible for, and enroll, in the HSA. Complete and submit it along with your Health Insurance Application/Change form to your human resources office.


Certificate of Coverage

Health Savings Account (HSA)

only available to individuals who are eligible for the HSA and enroll in either the HDHP or Access HDHP plan design

Summary of Benefits & Coverage

Plan Administrators

last updated: 4/24/2017

See Also