Additional Employee Resources
Plan Features
Everything You’ll Need to Know
Plan Documents
OPT- OUT PAYMENT (IN LIEU OF MEDICAL COVERAGE)
Coverage Information& Amounts
OPT-OUT PAYMENT (Medical only)
(Proof of employer sponsored medical insurance required) The elections you make will remain in effect until the end of the plan year unless you experience a life change event.
IBC - Medical Claim Form
Email to HR at [email protected]
IBC- Handicapped Child Application
Application to Continue Coverage for Disabled Dependent Child
IBC - PPO Claim Form Out-of-Network
Email to HR at [email protected]
IBC - Davis Vision Care Reimbursement
Claim Form
FSA Enrollment Form
FSA= Flexible Spending Account
Madison National Life Insurance Company, Inc. Change of Beneficiary Form
Upon completion of this form, keep a copy so that your beneficiaries may refer to it should a claim for Group Term Life benefits be necessary.
Madison National Insurance Services EOI Form
The EOI for the Long-Term Disability coverage is required for the National Insurance Services (NIS). Your coverage will drop if the EOI form is not submitted within 60 days after completing your enrollment process.
Websites
Contacts
Contact Human Resources if you have additional questions.
(610) 284-8005 ext. 1239
Email: [email protected] or [email protected]
Madison National Life Insurance Company
800.627.3660
For questions, please contact the plan administrator