Benefits Forms

Active Employees

Health Insurance

Harvard Pilgrim Health Care (PDF)

Fallon Community Health Plan (PDF)

Blue Cross Blue Shield (PDF)

Tufts Health Plan (PDF)

Other Benefits

Benefits Declination Form (PDF)

Opt Out Program form (must be eligible) (PDF)

Health Savings Account (HSA) Enrollment /Contribution Change Form (PDF)

Flexible Spending Account (FSA) Form (PDF)

Delta Dental (PDF)

Aflac Termination Form (PDF)

EyeMed - Vision Insurance Form (PDF)

Retirees

Non-Medicare Plans

Harvard Pilgrim Health Care (PDF)

Fallon Community Health Plan (PDF)

Blue Cross Blue Shield (PDF)

Tufts Health Plan (PDF)

Medicare Plans

Harvard Pilgrim Medicare Enhanced (PDF)

Fallon Senior Health Plan (PDF)

Blue Cross MEDEX (PDF)

Blue MedicareRx (PDF)

Blue Cross Managed Blue for Seniors (PDF)

Tufts Medicare Supplement PDP Plus (PDF)

Tufts Medicare Preferred HMO (PDF)