2020 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
2020 DOCUMENTS
Pre-65 DOCUMENTS

GENERAL INFORMATION

CARRIER MATERIALS

BCBSM COPPER 2020 HDHP PLAN BENEFITS
BCBSM BRONZE 2020 HDHP PLAN BENEFITS
BCBSM SILVER PPO 2020 PLAN BENEFITS
BCBSM GOLD PPO 2020 PLAN BENEIFTS
BCBSM MEDICARE DISABLED 2020 PLAN BENEFITS
POST 65 DOCUMENTS

GENERAL INFORMATION

CARRIER MATERIALS

ENROLLMENT FORMS / PRICING

2020 BCBSM PRE-65 ENROLLMENT FORM

ENROLLMENT FORMS

Two forms are required for enrollment for GRIP and SMIP Plans

BENEFIT ENROLLMENT FORM POST 65 GRIP
HARTFORD GRIP ENROLLMENT FORM
BENEFIT ENROLLMENT FORM POST 65 SMIP
HARTFORD SMIP ENROLLMENT FORM

DENTAL

DENTAL LOW PLAN 2020
DENTAL HIGH PLAN 2020
DENTAL & VISION PREMIUMS 2020
POST 65 DENTAL AND VISION FORM
MISC DOCUMENTS

MISC DOCUMENTS

HEALTH SAVINGS ACCOUNT

2020 HSA FAQ'S

HARDSHIP FUND

2020 HARDSHIP GRANT COVER LETTER
2020 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
BY LAWS

2020 ELECTION INFORMATION

2020 DSRA BT BoD CANDIDATE FILING INSTRUCTIONS
2020 DSRA BT BoD CANDIDATE REGISTRATION
2020 DSRA BT BoD CANDIDATE QUALIFICATIONS
CONFLICT OF INTEREST POLICY
DSRA BT RESUME FORM

2020 FINANCIALS

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

SUMMARY PLAN DOCUMENT

DSRA BT PLAN DOCUMENT (RESTATED 1/1/20)
DSRA BT PLAN DOCUMENT (RESTATED 1/1/18)

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