Forms Library

Selection	File type icon	File name	Description	Size	Revision	Time	User

	2020-2021 Benefits Overview

Selection	File type icon	File name	Description	Size	Revision	Time	User
	ĉ	19-08-01 Highmark Benefits Enrollment and Change Form.docx View Download		87k	v. 3	Apr 16, 2021, 12:55 PM	Courtney Akers
	Ċ	20-08-01 2020-2021 Summary of Benefits.pdf View Download		1645k	v. 2	Jun 15, 2020, 10:35 AM	Courtney Akers
	Ċ	20-08-01 Annual Notices Packet.pdf View Download		575k	v. 2	Jul 1, 2020, 12:29 PM	Courtney Akers
	Ċ	20-08-01 FSA Enrollment Guide.pdf View Download		487k	v. 2	Jun 18, 2020, 11:05 AM	Courtney Akers
	Ċ	20-08-01 HDHP Enhanced Preventative RX List.pdf View Download		805k	v. 2	Jun 14, 2020, 5:05 PM	Courtney Akers
	Ċ	20-08-01 Highmark Benefits Enrollment and Change Form.pdf View Download		622k	v. 2	Jun 18, 2020, 11:05 AM	Courtney Akers
	Ċ	20-08-01 Highmark Companies Benefit Digest 2020-2021.pdf View Download		20140k	v. 2	Jun 14, 2020, 5:16 PM	Courtney Akers
	Ċ	20-08-01 HSA Employee Contribution Form.pdf View Download		185k	v. 2	Jun 18, 2020, 11:05 AM	Courtney Akers
	Ċ	20-08-01 Medical Plan Comparisons.pdf View Download		91k	v. 2	Jun 14, 2020, 5:16 PM	Courtney Akers
	Ċ	20-08-01 Open Enrollment Memo -- Updated.pdf View Download		346k	v. 2	Aug 5, 2020, 7:49 AM	Courtney Akers
	Ċ	20-08-01 Payroll Deductions for 2020-2021.pdf View Download		39k	v. 2	Jun 15, 2020, 7:33 AM	Courtney Akers
	Ċ	20-08-01 ProBenefits FSA Enrollment Guide.pdf View Download		638k	v. 2	Jun 15, 2020, 10:14 AM	Courtney Akers
	Ċ	20-08-01 Summary of Benefits and Coverage Base Plan.pdf View Download		463k	v. 2	Jun 14, 2020, 5:16 PM	Courtney Akers
	Ċ	20-08-01 Summary of Benefits and Coverage Buy Up Plan.pdf View Download		466k	v. 2	Jun 14, 2020, 5:16 PM	Courtney Akers
	Ċ	20-08-01 Summary of Benefits and Coverage HDHP.pdf View Download		463k	v. 2	Jun 14, 2020, 5:16 PM	Courtney Akers
	Ċ	20-08-01 UHC Supplemental Life Enrollment Form.pdf View Download		200k	v. 2	Jun 18, 2020, 11:05 AM	Courtney Akers

	2021-2022 Benefits Overview

Selection	File type icon	File name	Description	Size	Revision	Time	User
	Ċ	21-08-01 Annual Notice Packet -- 2021 - 2022 Plan Year.pdf View Download		563k	v. 2	Jul 1, 2021, 1:14 PM	Courtney Akers
	Ċ	21-08-01 Highmark Benefits Digest 2021 -2022 Plan Year.pdf View Download		6236k	v. 3	Aug 9, 2021, 10:22 AM	Courtney Akers
	Ċ	21-08-01 Highmark Healthcare Premiums Payroll Deductions.pdf View Download		60k	v. 3	Jun 25, 2021, 5:25 PM	Courtney Akers
	Ċ	21-08-01 Highmark Open Enrollment Memo 2021 - 2022 Plan Year.pdf View Download		290k	v. 2	Jun 25, 2021, 9:08 AM	Courtney Akers
	Ċ	21-08-01 - Highmark_SBC Base Plan_UHC_Medical_202108.pdf View Download		834k	v. 2	Jul 15, 2021, 4:28 AM	Courtney Akers
	Ċ	21-08-01 - Highmark_SBC Buy-Up Plan_UHC_Medical_202108.pdf View Download		836k	v. 2	Jul 15, 2021, 4:28 AM	Courtney Akers
	Ċ	21-08-01 - Highmark_SBC HDHP with HSA_UHC_Medical_202108.pdf View Download		834k	v. 2	Jul 15, 2021, 4:28 AM	Courtney Akers
	Ċ	21-08-01 Medical Plan Comparison - 2021-2022 Plan Year.pdf View Download		114k	v. 2	Jun 25, 2021, 7:19 AM	Courtney Akers
	Ċ	21-08-01 Summary of Benefits.pdf View Download		177k	v. 4	Jan 14, 2022, 6:46 AM	Courtney Akers

	401(k) Forms

Selection	File type icon	File name	Description	Size	Revision	Time	User
	ĉ	17-10-11 401(k)DistributionRequest.doc View Download	401(k) Distribution Request Form	135k	v. 2	Oct 13, 2017, 1:37 PM	Courtney Akers
	ĉ	17-10-11 401(k)FinancialHardshipRequest.doc View Download	401(k) Financial Hardship Request Form	127k	v. 4	Nov 21, 2018, 10:00 AM	Courtney Akers
	ĉ	17-10-11 401(k)LoanApplicationRequest.doc View Download	401(k) Loan Application Request Form	114k	v. 2	Oct 13, 2017, 1:37 PM	Courtney Akers
	Ċ	19-01-01 401(k) SPD.pdf View Download	401(k) Summary Plan Description	359k	v. 2	Dec 7, 2018, 9:31 AM	Courtney Akers
	Ċ	20-09-01 401(k) Enrollment Booklet.pdf View Download		2220k	v. 2	Sep 2, 2020, 5:39 AM	Courtney Akers
	Ċ	20-12-01 Participant Fee Disclosure Notice for 2021.PDF View Download		78k	v. 2	Nov 16, 2020, 6:13 PM	Courtney Akers
	Ċ	20-12-01 QDIA Notice for 2021.pdf View Download		67k	v. 2	Nov 16, 2020, 6:13 PM	Courtney Akers
	Ċ	20-12-01 Safe Harbor Notice for 2021.pdf View Download		68k	v. 2	Nov 16, 2020, 6:13 PM	Courtney Akers
	Ċ	2019 401(k) Eligibility Requirements.pdf View Download	401(k) Eligibility Requirements -- 2019	92k	v. 2	Apr 10, 2019, 1:27 PM	Courtney Akers
	Ċ	2020 Participant Fee Disclosure Notice--19-11-18 Updated on 20-04-23.pdf View Download		301k	v. 2	Aug 5, 2020, 7:57 AM	Courtney Akers
	Ċ	21-06-15 401k Enrollment Form.pdf View Download		77k	v. 2	Jun 16, 2021, 11:04 AM	Courtney Akers
	Ċ	22-06-01 401k Rollover Contribution Form.pdf View Download		65k	v. 2	Jun 13, 2022, 6:27 AM	Courtney Akers
	ĉ	401(k)BeneficiaryDesignationForm2011-12-01.doc View Download	401(k) Beneficiary Designation Form	110k	v. 2	Dec 14, 2011, 7:17 PM	Unknown user
	ĉ	401(k)DeathBenefitRequest2011-12-01.doc View Download	401(k) Death Benefit Request Form	130k	v. 2	Jul 7, 2016, 11:45 AM	Courtney Akers
	Ċ	401(k)DeathBenefitRequest-Notice.pdf View Download	401(k) Death Benefit Request - Tax Notice	114k	v. 4	Jul 7, 2016, 11:45 AM	Courtney Akers
	ĉ	401(k)DeferralElectionChange 2014.doc View Download	401(k) Deferral Election Change Form	94k	v. 2	Nov 27, 2013, 5:59 AM	Unknown user
	Ċ	401(k)DistributionRequest-Notice.pdf View Download	401(k) Distribution Request - Tax Notice	114k	v. 3	Jul 7, 2016, 11:47 AM	Courtney Akers
	Ċ	401(k)FinancialHardshipRequest-Notice.pdf View Download	401(k) Financial Hardship Request - Tax Notice	114k	v. 4	Nov 21, 2018, 10:00 AM	Courtney Akers
	Ċ	401(k)ParticipantFormOverview.pdf View Download	401(k) Overview of Participant Forms	22k	v. 4	Mar 2, 2010, 7:50 PM	Unknown user

	Flexible Spending Forms

Selection	File type icon	File name	Description	Size	Revision	Time	User
	Ċ	17-08-01 FSA Direct Deposit Form.pdf View Download	FSA Direct Deposit Form	802k	v. 2	Jun 15, 2017, 8:29 AM	Courtney Akers
	Ċ	19-08-01 Flexible Spending Account (FSA) Claim Form.pdf View Download		408k	v. 2	Jun 26, 2019, 7:01 AM	Courtney Akers
	Ċ	19-08-01 Flexible Spending Account (FSA) Enrollment Guide.pdf View Download		2619k	v. 2	Jun 26, 2019, 6:45 AM	Courtney Akers
	Ċ	19-08-01 FSA Enrollment Form.pdf View Download		332k	v. 2	Jun 26, 2019, 9:04 AM	Courtney Akers
	Ċ	2014 ProBenefits Claim Form.pdf View Download	FSA Claim Form - effective through 7/31/18	64k	v. 2	Jul 7, 2017, 9:37 AM	Courtney Akers
	Ċ	ProBenefitsFSAPlanParticipationForm.pdf View Download	FSA Plan Participation Form	59k	v. 7	Dec 29, 2016, 6:34 AM	Courtney Akers

	Holiday Schedules

Selection	File type icon	File name	Description	Size	Revision	Time	User
	Ċ	22-01-01 Corporate Division Holiday Schedule.pdf View Download		217k	v. 3	Feb 7, 2022, 1:35 PM	Courtney Akers
	Ċ	22-01-01 LabCorp Holiday Schedule.pdf View Download		241k	v. 3	Jan 14, 2022, 6:42 AM	Courtney Akers

	International Travel

Selection	File type icon	File name	Description	Size	Revision	Time	User
	Ċ	11-06-17InternationalTravelCheckList.pdf View Download	International Travel Checklist	386k	v. 2	Jun 22, 2011, 5:43 PM	Unknown user

	Job Application

Selection	File type icon	File name	Description	Size	Revision	Time	User
	ĉ	16-04-20 Highmark Employment Application.doc View Download	Employment Application	189k	v. 3	Apr 20, 2016, 10:04 AM	Courtney Akers
	Ċ	17-01-01 USCIS I-9-paper-version.pdf View Download	USCIS Form I-9 (Paper Version)	73k	v. 2	Oct 13, 2017, 1:41 PM	Courtney Akers
	Ċ	E-Verify Notice--2013.pdf View Download		628k	v. 3	Sep 5, 2014, 12:36 PM	Unknown user

	Life or Disability Forms

Selection	File type icon	File name	Description	Size	Revision	Time	User
	Ċ	19-08-01 Beneficiary Designation Change for Life Insurance.pdf View Download		80k	v. 2	Oct 24, 2019, 11:40 AM	Courtney Akers
	Ċ	19-08-01 UHC Life Member Welcome Brochure.pdf View Download		564k	v. 2	Sep 17, 2019, 10:54 AM	Courtney Akers
	Ċ	19-08-01 UHC Supplemental Life Enrollment Form.pdf View Download		119k	v. 2	Jun 26, 2019, 6:36 AM	Courtney Akers
	Ċ	20-08-01 Highmark Companies Life COC.pdf View Download		249k	v. 2	Sep 29, 2020, 6:52 AM	Courtney Akers
	Ċ	20-08-01 Highmark Companies LTD Class 1 COC.pdf View Download		217k	v. 2	Sep 29, 2020, 6:52 AM	Courtney Akers
	Ċ	20-08-01 Highmark Companies LTD Class 2 COC.pdf View Download		217k	v. 2	Sep 29, 2020, 6:52 AM	Courtney Akers
	Ċ	2019 LTD Claim Form (Rev 01_18).pdf View Download		810k	v. 2	Oct 3, 2019, 12:07 PM	Courtney Akers
	Ċ	2019 LTD Welcome Brochure.pdf View Download		495k	v. 2	Oct 3, 2019, 12:07 PM	Courtney Akers
	Ċ	21-01-01 Highmark Companies Contract SPD Certificate UHC Certificate of Coverage Group Life ADD.pdf View Download		253k	v. 2	Apr 16, 2021, 6:28 AM	Courtney Akers
	Ċ	21-01-01 Highmark Companies Contract SPD Certificate UHC Certificate of Coverage LTD All Full Time Employees.pdf View Download		220k	v. 2	Apr 16, 2021, 6:28 AM	Courtney Akers
	Ċ	21-01-01 Highmark Contract UHC STD COC_Class 1.pdf View Download		204k	v. 2	Apr 16, 2021, 6:28 AM	Courtney Akers
	Ċ	21-01-01 Short-Term Disability Brochure.pdf View Download		5170k	v. 3	Apr 16, 2021, 1:05 PM	Courtney Akers
	Ċ	21-06-25 Long-Term Disability -- Summary of Benefits.pdf View Download		197k	v. 2	Jun 25, 2021, 6:13 AM	Courtney Akers
	Ċ	Basic Life - AD&D - Voluntary Life Plan Description.pdf View Download		585k	v. 2	Oct 24, 2019, 11:08 AM	Courtney Akers
	Ċ	UHIC Life Claim Form for all other states--Rev 01_18.pdf View Download		129k	v. 3	Oct 3, 2019, 12:06 PM	Courtney Akers
	Ċ	UHIC Life Claim Form for Beneficiaries residing in AR CO KS MD NC ND NV NY--REV 10_14.pdf View Download		64k	v. 3	Oct 3, 2019, 12:06 PM	Courtney Akers

	Medical and Dental Forms

Selection	File type icon	File name	Description	Size	Revision	Time	User
	Ċ	16-07-07 UHC HIPAA Disclosure Authorization Form.pdf View Download	United Healthcare HIPAA Disclosure Authorization Form	86k	v. 3	Jul 7, 2016, 1:02 PM	Courtney Akers
	Ċ	16-07-07 UHC Rx Prescription Reimbursement Form.pdf View Download	United Healthcare Prescription Reimbursement Request Form	646k	v. 5	Jul 13, 2017, 2:18 PM	Courtney Akers
	Ċ	17-08-01 Guardian Dental SPD - Summary Plan Description ending 7-31-2018--V07122017.pdf View Download	Guardian - Summary Plan Description for Dental Coverage -- effective through 7/31/2018	62k	v. 2	Aug 30, 2017, 7:03 AM	Courtney Akers
	Ċ	17-08-01 Highmark Companies HSA Summary.pdf View Download	HSA Summary - effective through 7/31/2018	1117k	v. 2	Aug 30, 2017, 7:03 AM	Courtney Akers
	Ċ	17-08-01 HSA Employee Contribution Form.pdf View Download	HSA Employee Contribution Form -- effective through 7/31/2018	168k	v. 2	Jul 13, 2017, 3:02 PM	Courtney Akers
	Ċ	18-08-01 HDHP Preventive Medications List for 2018-2019.pdf View Download	2018 Preventive Drug List for HDHP/HSA Health Plan -- Plan Year 2018-2019	854k	v. 3	Aug 15, 2018, 8:27 AM	Courtney Akers
	ĉ	18-08-01 Highmark Benefits Enrollment and Change Form.doc View Download	Benefits Enrollment and Change Form -- Effective through 7/31/2019	171k	v. 3	Jun 18, 2018, 1:02 PM	Courtney Akers
	Ċ	18-08-01 Highmark Companies HSA Summary.pdf View Download		184k	v. 2	Oct 24, 2019, 11:33 AM	Courtney Akers
	Ċ	18-08-01 UHC Dental Benefit Summary.pdf View Download	United Healthcare Dental Plan Summary -- effective 8/1/18 - 7/31/19	172k	v. 2	Jun 18, 2018, 1:02 PM	Courtney Akers
	Ċ	19-08-01 2019 HDHP Enhanced Preventative Prescription Drugs List.pdf View Download		792k	v. 2	Jun 26, 2019, 6:45 AM	Courtney Akers
	Ċ	19-08-01 UHC SBC Base Plan.pdf View Download	Summary of Benefits for United Healthcare Base Plan -- effective through 7/31/2020	464k	v. 2	Aug 14, 2019, 10:42 AM	Courtney Akers
	Ċ	19-08-01 UHC SBC Buy-Up Plan.pdf View Download	Summary of Benefits for United Healthcare Buy-Up Plan -- effective through 7/31/2020	466k	v. 2	Aug 14, 2019, 10:43 AM	Courtney Akers
	Ċ	20-08-01 Highmark Companies_Certificate of Coverage HSA Medical Plan.pdf View Download		1434k	v. 2	Sep 29, 2020, 6:52 AM	Courtney Akers
	Ċ	20-08-01 Highmark Companies_Certificate of Coverage Medical Base Plan.pdf View Download		1273k	v. 2	Sep 29, 2020, 6:52 AM	Courtney Akers
	Ċ	20-08-01 Highmark Companies_Certificate of Coverage Medical Buy Up Plan.pdf View Download		1439k	v. 2	Sep 29, 2020, 6:52 AM	Courtney Akers
	Ċ	20-08-01 Highmark Companies Dental COC.pdf View Download		600k	v. 2	Sep 29, 2020, 6:52 AM	Courtney Akers
	Ċ	20-08-01 Highmark Companies Vision COC.pdf View Download		605k	v. 2	Sep 29, 2020, 6:52 AM	Courtney Akers
	Ċ	2019 BLT5 Buy-Up Medical Plan Benefit Summary.pdf View Download		414k	v. 2	Oct 9, 2019, 7:57 AM	Courtney Akers
	Ċ	2019 BLUZ HSA Medical Plan Benefit Summary.pdf View Download		411k	v. 2	Oct 9, 2019, 7:57 AM	Courtney Akers
	Ċ	2019 BLVC Base Medical Plan Benefit Summary.pdf View Download		410k	v. 2	Oct 9, 2019, 7:57 AM	Courtney Akers
	Ċ	2019 OptumRX Welcome Brochure.pdf View Download		1613k	v. 2	Sep 25, 2019, 1:53 PM	Courtney Akers
	Ċ	2019 Prescription Mail Order Flier.pdf View Download		702k	v. 2	Sep 25, 2019, 1:53 PM	Courtney Akers
	Ċ	2019 Prescription Mail Order Form.pdf View Download		118k	v. 2	Sep 25, 2019, 1:53 PM	Courtney Akers
	Ċ	21-05-01 3-Tier Prescription Drug List (Base and Buy-Up Plans).pdf View Download		1344k	v. 2	Jun 25, 2021, 6:26 AM	Courtney Akers
	Ċ	21-05-01 4-Tier Prescription Drug List (HDHP:HSA Plan).pdf View Download		2030k	v. 2	Jun 25, 2021, 6:26 AM	Courtney Akers
	Ċ	21-06-24 Summary of Benefits -- Vision.pdf View Download		66k	v. 2	Jun 25, 2021, 6:26 AM	Courtney Akers
	Ċ	21-09-01 3-Tier Prescription Drug List (Base and Buy-Up Plans).pdf View Download		1384k	v. 2	Jun 25, 2021, 6:26 AM	Courtney Akers
	Ċ	21-09-01 4-Tier Prescription Drug List (HDHP:HSA Plan).pdf View Download		824k	v. 2	Jun 25, 2021, 6:26 AM	Courtney Akers
	Ċ	UnitedHealthPrescriptionDrugFAQs.pdf View Download	United Health Prescription Drug FAQs	56k	v. 4	Apr 16, 2021, 12:55 PM	Courtney Akers

	Payroll Forms

Selection	File type icon	File name	Description	Size	Revision	Time	User
	Ċ	21-01-01 Bi-Weekly Payroll Calendar.pdf View Download		43k	v. 2	Jan 14, 2021, 7:18 AM	Courtney Akers
	Ċ	21-01-01 Semi-Monthly Payroll Calendar.pdf View Download		47k	v. 2	Jan 14, 2021, 7:18 AM	Courtney Akers
	Ċ	22-01-01 2022 Bi-Weekly Payroll Calendar.pdf View Download		45k	v. 2	Apr 4, 2022, 4:58 PM	Courtney Akers
	Ċ	22-01-01 2022 Semi-Monthly Payroll Calendar.pdf View Download		45k	v. 2	Apr 4, 2022, 5:04 PM	Courtney Akers
	ĉ	PayrollDeposit.2009-10-27.doc View Download	Payroll Direct Deposit Form	125k	v. 3	Jul 3, 2014, 7:42 AM	Unknown user
	Ċ	SPD for Flexible Benefit Plan effective 8-1-2020.pdf View Download		541k	v. 3	Jan 14, 2021, 7:18 AM	Courtney Akers

	Reimbursement Forms

Selection	File type icon	File name	Description	Size	Revision	Time	User
	ĉ	18-01-01 Home Office Reimbursement Approval Form.doc View Download	Home Office Reimbursement Approval Form -- Effective January 1, 2018	89k	v. 2	Nov 27, 2017, 2:28 PM	Courtney Akers
	Ċ	18-01-01 Home Office Reimbursement Policy.pdf View Download	Home Office Reimbursement Policy -- Effective January 1, 2018	150k	v. 2	Nov 27, 2017, 2:28 PM	Courtney Akers
	ĉ	18-01-01 Voice and Data Reimbursement Approval Form.doc View Download	Voice/Data Reimbursement Approval Form -- Effective January 1, 2018	91k	v. 2	Nov 27, 2017, 2:28 PM	Courtney Akers
	Ċ	18-01-01 Voice Data Reimbursement Policy.pdf View Download	Voice/Data Reimbursement Policy -- Effective January 1, 2018	160k	v. 2	Nov 27, 2017, 2:27 PM	Courtney Akers

	Tax Forms

Selection	File type icon	File name	Description	Size	Revision	Time	User
	Ċ	17-01-01 California Form DE-4.pdf View Download	California Tax Withholding Form	79k	v. 2	Oct 13, 2017, 1:44 PM	Courtney Akers
	Ċ	18-01-01 NC-4EZ.pdf View Download	NC Tax Withholding Form - NC-4EZ	2275k	v. 2	Nov 21, 2018, 9:59 AM	Courtney Akers
	Ċ	18-01-01 NC-4.pdf View Download	NC Tax Withholding Form - NC-4	2318k	v. 2	Nov 21, 2018, 9:59 AM	Courtney Akers
	Ċ	20-01-01 W-4 for 2020.pdf View Download	Federal Tax Withholding Form W-4 (eff. 2020)	82k	v. 2	Jan 3, 2020, 12:45 PM	Courtney Akers
	Ċ	NC-4 Employees Withholding Allowance Certificate 12-2018.pdf View Download		445k	v. 2	Jun 26, 2019, 7:06 AM	Courtney Akers
	Ċ	NC-4 EZ Employee Withholding Allowance Certificate 12-2018.pdf View Download		408k	v. 2	Jun 26, 2019, 7:06 AM	Courtney Akers