Health Benefits / Life Insurance Forms & Information
Health Benefits
- NEW! Notice of Privacy Practices
- Premera Privacy Policy and Practices 2016
- 2015-2016 Rate Contributions
- 2016 Premera Plan Book
- 2016-2017 Economy Summary of Benefits
- 2016-2017 Standard Summary of Benefits
- 2016-2017 Premium Summary of Benefits
- Health Coverage and Medical Terms Glossary
USAble Life Insurance
AFLAC Group Voluntary Benefits
- AFLAC Group Enrollment Form
- AFLAC Group Disability Insurance
- AFLAC Group Accident Insurance
- AFLAC Group Critical Illness Insurance
Flex Spending Account Program
- Flex Spending Enrollment Form
- 2016-2017 Flex Spending ProgramBAC Mobile App Instructions
- Activating Your Account Instructions
- BAC Mobile App Instructions
The following link contains information on the New Health Insurance Marketplace Coverage offered as part of healthcare reform. If you are currently benefited under CBJ’s health insurance, you do not need to do anything. If you do not have coverage, read through the information and if you have any questions, please contact the Risk Management Specialist.
Health Benefits / Life Insurance Forms & Information
- HIPAA Privacy Notice – policies and practices to protect the confidentiality of plan participants’ health information
- 24-Hour NurseLine
- Employee Forms
- Enrollment/Change Form
- Medical, Dental, Vision Claim Form
- Transportation Reimbursement Form
- Travel Benefit Advisory Form
- Prescription Claim Form:
- Express Scripts Mail Order Form – for Employee’s Use
- Express Scripts Fax Order Form – for Health Care Professional’s Use
- Prescription Reimbursement Form
- Secondary Insurance RX Claim Form
- Part-time Employee Benefit Prorate Forms:
- 75 Hour Work Week (MEBA & Un-Rep)
- 80 Hour Work Week (MEBA & Un-Rep)
- 80 Hour Work Week (PSEA)
- Firefighter Worksheet
- COBRA Benefits
- Premera Health Insurance
- Cigna Life Insurance
- Express Scripts Mail Order Prescriptions (Phone: (800) 391-9701)
- Employee Assistance Program – ComPsych® has been contracted by CBJ to provide support, resources and information to employees and their family on a confidential basis, at no charge to you, as a company-sponsored benefit. Employees and family members are encouraged to visit the ComPsych® website at www.guidanceresources.com or talk with a ComPsych representative by calling 1-800-295-9059 (TDD: 1-800-697-0353). To set up an online membership or to speak with a Guidance Consultant, you will need to provide the following company ID: CITYJEAP2.
- Retirement Plans
- Flexible Spending Account (FSA)
- FSA program details
- Flexible Spending Account Info-not sure if you want to participate in the Flex Spending program…read this handout.
- Authorization for Direct Deposit
- Health Care Reimbursement form
- Dependent Care Claim form