Friday, November 27, 2015
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MyBenefits & Wellness Home

MyBenefits Resources and Links to Websites

Forms & Resources

Summary of Benefits and Coverage Glossary

BlueCross BlueShield of Nebraska

Coordination of Benefits Questionnaire

Non-Participating Provider Claim

Prescription Drug Claim

PrimeMail Order Form

Specialty Drug List

Vision Claim Form

BlueCard Worldwide Claim

Teledoc flier

Teladoc Set Up Instructions 

                    Tier I PPO Medical Plan Summary - 2015

                    Tier I PPO Medical Plan Document - 2015

                    Tier II PPO Medical Plan Summary - 2015

                    Tier II PPO Medical Plan Document - 2015

                    Tier III PPO Medical Plan Summary - 2015

                    Tier III PPO Medical Plan Document - 2015

Business Discounts Flier

Cigna Group Insurance

Life Insurance Application

          LTD Evidence of Insurability (EOI) 

          LTD Conversion Form

          Life Insurance Conversion Form

Colonial Supplemental Insurance (Supplemental Policies)

Request for Service (change) Form

Universal Claim Form

 DailyAccess Corporation 403(b) (Retirement Plan)

Designation of Beneficiary

403(b) Distribution

Enrollment and Change Application

Hardship Withdrawal Request

Incoming Rollover

Direct Deposit Form

Education Compensation (Tuition Assistance) Application

Education Compensation Committee Scoring Sheet

Employee Request Form (Request for Time Off)

          Gallagher Grace Mayer (Flex Spending Accounts & HRA)  

                    FSA & Daycare Reimbursement Claim Form

                    Teladoc HRA Claim Form 

                    MyFlex Online Mobile App for iPhone 

                    MyFlex Online Mobile App for Android Devices  

          Health & Dental Premiums - 2015

HIPAA Notice

Insurance Providers & Contact Info

Lifeworks (Ceridian) EAP Informational Flier

PeopleSoft Self Service Manual

Qualified Change in Family Status 2015

Request for FMLA

Request for PTO Assistance

W4- 2015

The Work Number Flier

 links to websites

BlueCross BlueShield of Nebraska                                    

Blue Health Advantage                                                      

Colonial Supplemental Insurance                                      

Connection Dental – Find a Dentist                                  

Cypress Benefit Administrators                                       

DailyAccess Corporation                                                  

Grace/Mayer Gallagher – EZ Flex Plan                             

LifeWorks EAP Resource                                                 

Simply Well Health Solutions