2021 FORMS & DOCUMENTS

forms
Pre-65 forms
post-65 forms
Hardship fund

Open enrollment form

Copper Plan

IRS 13441A Form

ALL MEMBERS
Guardian Beneficiary Designation Change Form
2021 DOCUMENTS
Pre-65 DOCUMENTS

GENERAL INFORMATION

CARRIER MATERIALS

BCBSM COPPER 2021 HDHP PLAN BENEFITS
BCBSM BRONZE 2021 HDHP PLAN BENEFITS
BCBSM SILVER PPO 2021 PLAN BENEFITS
BCBSM GOLD PPO 2021 PLAN BENEIFTS
POST 65 DOCUMENTS

GENERAL INFORMATION

CARRIER MATERIALS

BCBSM MEDICARE DISABLED 2021 PLAN BENEFITS

ENROLLMENT FORMS

ENROLLMENT FORMS / PRICING

2021 BCBSM PRE-65 ENROLLMENT FORM

Two forms are required for enrollment for The Hartford Plans

BENEFIT ENROLLMENT FORM POST 65
HARTFORD ENROLLMENT FORM
POST 65 DENTAL AND VISION FORM

DENTAL

DENTAL LOW PLAN 2021
DENTAL HIGH PLAN 2021
DENTAL & VISION PREMIUMS 2021
MISC DOCUMENTS

MISC DOCUMENTS

HEALTH SAVINGS ACCOUNT

2021 HSA FAQ'S

HARDSHIP FUND

HARDSHIP GRAND APPLICATION

LIFE INSURANCE

GUARDIAN BENEFICIARY DESIGNATION CHANGE FORM
CHIP MODEL NOTICE
WHCRA NOTICE

HELPFUL TOOLS

IRS 8885 FORM INSTRUCTIONS
SAMPLE 13441A ADDRESS CHANGE
SAMPLE 13441A NEW AMP ENROLLMENT
SAMPLE 13441A QFM
SAMPLE 13441A COVERAGE CHANGES
dsra benefit trust documents

2021 FINANCIALS

Q1 FINANCIALS 2021
Q2 FINANCIALS 2021
Q3 FINANCIALS 2021
Q4 FINANCIALS 2021

SUMMARY PLAN DOCUMENT

DSRA BT PLAN DOCUMENT (RESTATED 1/1/20)

DSRA BT BoD Election 2021

DSRA BT BoD Candidate Request

TRUST AGREEMENT

1114 COMMITTEE FINAL REPORT
FIRST AMENDED & RESTATED TRUST AGREEMENT
ORIG TRUST AGREEMENT WITH HARDSHIP PROCESS
SECOND AMENDED & RESTATED TRUST AGREEMENT
TA & BYLAWS SUMMARY CHANGES
QUARTERLY TRUST
FINANCIAL REPORTS

2010 FINANCIALS

2010 Q4 FINANCIALS
2010 Q3 FINANCIALS
2010 Q2 FINANCIALS
2010 Q1 FINANCIALS

2009 FINANCIALS

2009 Q4 FINANCIALS
2009 Q3 FINANCIALS
2009 Q2 FINANCIALS
2009 Q1 FINANCIALS
summary PLAN DOCUMENT

2020 FINANCIALS

Q1 FINANCIALS 2020
Q2 FINANCIALS 2020
Q3 FINANCIALS 2020
Q4 FINANCIALS 2020