Health & Welfare Benefits

Health & Welfare- Contact Information

Costco Mail Order

Medical Temporary ID Card

Medical Enrollment Form

Medical Change Form (add/remove dependents and change name or address)

Delta Dental Election Form

Delta Dental Phone App

Basic Life/AD&D Insurance Enrollment Form

Payroll Address Name Change

SISC Flex Plan Online Enrollment Instructions

Flex Plan Enrollment

Flex Plan Change Form

Basic Life/Voluntary Life Change Form

Voluntary Term Life Insurance Enrollment Form

Dependent Eligibility Documentation Chart

Proof of Death Claim Form

Envoy Retirement Savings Plan - 403B

Certificated Plan Election Form

Plan 40691C (90C)

Plan 40691B (90E)

Plan 40691D (80G)

Plan 40728A (80K)

Plan 40728B (Minimum Value Plan)

Plan 70691B (2-Tier Anchor Bronze, No Dental/Vision

Dental 7082-1210 (Premier Incentive Unlimited)

Dental 7082-1225 (PPO $1500 Maximum) 

Vision 2499570A (VSP Signature A $20)

Classified Plan Election Form

Plan 40728C (100B)

Plan 40691A (90C)

Plan 40691E (80E)

Plan 40691F (80K)

Plan 70728B (2-Tier Anchor Bronze, No Dental/Vision/Life)

Dental 7082-1010 (Premier Incentive Unlimited)

Dental 7082-1021 (PPO $2000 Max)

Vision 2073591A (VSP Signature A $20)

Life Benefits Summary (Active Employee Only G00ABIH $100,000)

Voluntary Term Life Insurance information

Evidence of Insurability (for any additional life insurance above min. coverage)

Plan 40691J (100B)

Plan 40691G (80G)

Plan 40691H (80K)

Plan 40691K (80M) 

Plan 70692B (2-Tier Anchor Bronze, No Dental, No Vision)

Dental 7082-1410 (Unlimited-No Ortho)

Dental 7082-1610 (PPO $1500 Maximum)

Vision 2499556A (VSP Signature A $0/$25)

Life Benefits Summary (Active Employee Only G00ABIH-65C $100,000)

Voluntary Term Life Insurance Information

Evidence of Insurability (for any additional life insurance above min. coverage)