Benefits Info & Forms

are available whenever you need them. All forms are in .pdf format unless otherwise noted.

AcrobatReader

(which you probably have) is needed to download .pdf forms.

Please turn in signed paperwork to the Human Resources Department for all changes.

Insurance | Medical, Vision, Dental

A Life Event change must be reported within 31 days of the event, or the change will not become effective until the next Open Enrollment period. 

Benefit Summaries (2009-2010 Plan Year)	Faculty Administrators and Professional (Exempt) Staff Non-Exempt Staff Non-Exempt-Staff (Facilities and Public Safety) Flexible Benefits Worksheet (2009-2010) Summary Plan Description
Blue Care®  PPO	Benefit Summary Enrollment/Change Form Claim Form Dependent Supplement Mail Order Pharmacy Application Tier Zero Prescription Drugs Website: www.bcnepa.com ; www.bcbs.com Phone Number: 1-888-338-2211
Blue Care® HMO	Benefit Summary Enrollment/Change Form Dependent Supplement Mail Order Pharmacy Application Tier Zero Prescription Drugs Website: www.bcnepa.com Phone Number: 1-800-822-8753
Blue Care® HMO Plus (POS)	Benefit Summary  Enrollment/Change Form Dependent Supplement Mail Order Pharmacy Application Tier Zero Prescription Drugs Website: www.bcnepa.com Phone Number: 1-800-822-8753
United Concordia Dental	Basic Dental Booklet Enhanced Dental Booklet  Enrollment/Change Form  Identification Card Information Website: www.ucci.com Phone Number: 1-800-332-0366
Davis Vision	Benefit Summary Enrollment/Change Form Website: http://idoc.davisvision.com Phone Number: 1-800-406-1324
Flexible Spending Accounts (AmeriFlex 06/01/2009- 05/31/2010)	Enrollment Form  Direct Deposit Election Claim Form Eligible Expenses (Medical FSA) Change to Benefit AND/OR Election Website: www.flex125.com Phone Number: 1-888-868-FLEX (3539)
Flexible Spending Accounts (Loomis 06/01/2008- 05/31/2009)	Claim Form Direct Deposit Election Eligible Expenses (Medical FSA) Website: https://www.mbicard.com/default.aspx Phone Number: 1-800-253-5998
SunLife (Life and AD&D)	Beneficiary Form  Optional Life Enrollment Form Evidence of Insurability Supplemental Term Life Rate Sheet Supplemental AD&D Rate Sheet
TIAA-CREF	2009 Contribution Information Wilkes University Pension DC 103455 SPD Wilkes University Pension TDA 103457 SPD Salary Reduction Agreement (Word format)
Tuition Remission	Employee Spouse/Dependant Tuition Benefit Policy
Workers' Compensation	Policy/Procedures Workers' Compensation General Information Employee Injury Report  Notice of Rights and Duties  Panel Providers  Release of Medical Information  Supervisor Checklist