Insurance Coverage Information and Forms

Forms | Cost | Coverage Info

Enrollment Forms

NEW EMPLOYEES – Below you will find the information you need to make your benefit elections. Please review this information prior to your Orientation Meeting with Human Resources. Complete the Benefit Election form below and the Enrollment form for each type of benefit you elect, and bring the signed forms with you to your Orientation appointment.

All Benefit-eligible employees must complete these forms, sign, date and submit them to Human Resources. If you wish to waive any of the benefits, complete the section with your name and personal information and write "Waive" across the top of the form.

Cost of Insurance Plans

Medical Insurance

Cigna Open Access Plus
cigna.com | 1-800-Cigna24 (1-800-244-6224)

Cigna Option I:
Cigna Medical Plan I
(90%/10%)
Plan I Per Month
Employee Only $674.12
Employee + 1 $1,384.07
Employee + Family $1,958.79
Cigna Option II:
Cigna Medical Plan II
(80%/20%)
Plan II Per Month
Employee Only $665.84
Employee + 1 $1,367.09
Employee + Family $1,934.78

Dental Insurance

Cigna Dental PPO, Core Network
cigna.com | 1-800-Cigna24 (1-800-244-6224)

Cigna Dental:
Coverage OptionsCost Per Month
Employee Only $28.72
Employee + Family $86.54

Vision Insurance

EyeMed Vision Care (Insight)
eyemed.com | 1-866-939-3633

EyeMed Vision Care:
Coverage OptionsCost Per Month
Employee Only $5.42
Employee + Spouse $10.29
Employee + Children $10.83
Employee + Family $15.91

Life/Accidental Death and Dismemberment Insurance

Reliance Standard Life Insurance Company

Reliance Standard:
Coverage OptionsCost Per Month
Group Minimal cost for this required coverage.
Voluntary Rates are based on amount of coverage, age and tobacco use.

Long Term Disability Insurance

The Hartford

The Hartford:
Coverage OptionsCost Per Month
Option 1 (60 day EP) = $.47/$100 of covered payroll
Option 2 (90 day EP) = $.33/$100 of covered payroll
Option 3 (180 day EP) = $.24/$100 of covered payroll

Insurance Coverage Information

Medical Plan

Cigna HealthCare provides our medical and dental insurance. The following documents will help you learn more about your coverage.

Dental Plan

Vision Plan

EyeMed provides our Vision insurance. The following documents will help you learn more about your coverage.

Long Term Disability Plan

The Hartford provides our Long Term Disability (LTD) insurance. The following documents will help you learn about your coverage options.

Life Insurance Plan

Reliance Standard Life Insurance Company provides our life insurance. The following documents will help you learn about your coverage options.

Voluntary Term Life and AD&D Insurance Benefits Summary and Rate Tables – This provides information about the rates and terms of your Life Insurance Benefits.