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Form

Description

Form used to submit Medical claims to your health insurance.

 

Form used to submit Vision claims to your health insurance. (Fill with Acrobat)

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Non-CIGNA claims such as Vision claims and Dental Claims can be Faxed to: 630-286-4687

Coordination of Benefits - Accident Form

Important form required by PBA to ensure accidents are not liable to another party's insurance (auto, business, homeowners, etc.)

 

Form used to submit dental claims.

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Non-CIGNA claims such as Vision claims and Dental Claims can be Faxed to: 630-286-4687

Plan Documents & Other Forms

Choice Plan with HRA

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Choice Plan - Short Description

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Choice Plan - Full Plan Description 

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Basic Plan with HSA

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Basic Plan - Short Description

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COVID Amendment 03/30/20

Easy-to-read description of most frequently used coverage in the Employee Choice/HRA Plan as required by Health Care Reform.

Basic Health Plan with HSA Short Summary Plan Description

 

Easy-to-read description of Basic Health Plan with Health Savings Account Option. 

Basic Health Plan with HSA Complete Summary Plan 

1/1/18 (Valid until updated)

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Complete description of Basic Health Plan with Health Reimbursement Account Option 

Dental Summary Plan Description 
1/1/18 (Valid until updated)
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