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)
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.
Non-CIGNA claims such as Vision claims and Dental Claims can be Faxed to: 630-286-4687
Plan Documents & Other Forms
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)
Complete description of Basic Health Plan with Health Reimbursement Account Option
Dental Summary Plan Description
1/1/18 (Valid until updated)