Faculty Benefits

CHEIBA FORMS/DOCUMENTS

Anthem Medical/Dental/Vision
2018 Anthem Enrollment/Change FormPDF versionText only version
CHEIBA Waiver of InsurancePDF versionText only version
Flu Shot Reimbursement FormPDF versionText only version

Anthem Basic Life
Anthem Basic Life Insurance Enrollment FormPDF versionText only version
Anthem Basic Life Insurance Beneficiary EnrollmentPDF versionText only version

CHUBB Travel / Accident Insurance
CHUBB Beneficiary Enrollment FormPDF versionText only version

Flexible Spending Acct - 24Hour Flex
2017 Flexible Spending Account Enrollment FormPDF versionText only version
2017 24Hour Flex Enrollment GuidePDF versionText only version

Domestic Partnership Information and Forms
Statement of Termination of Domestic PartnershipPDF versionText only version

Dependent Eligibility Verification Documents and Forms
Dependent Eligibility Verification RequirementsPDF versionText only version
Affidavit of Common Law MarriagePDF versionText only version

Certificates of Coverage
2014 Final Custom Plus CertificatePDF versionText only version
2014 Final HMO-POS CertificatePDF versionText only version
2014 Final Prime PPO CertificatePDF versionText only version

2017 Open Enrollment
How to Locate a PPO Primary Care Physician (PCP)PDF versionText only version


2018 Open Enrollment
2018 Plan Change SummaryPDF versionText only version
2018 Flexible Spending Enrollment FormPDF versionText only version
2018 Voluntary Life Insurance PacketPDF versionText only version

Voluntary Life / AD&D
Anthem Life Voluntary Life InsurancePDF versionText only version
Mutual of Omaha Accidental Death & Dismemberment FormPDF versionText only version


 

 

 

 

 

 

 

 

 

 

2017 CHEIBA Documents
CHEIBA Booklet 2017PDF versionText only version
2017 Rate SheetPDF versionText only version
Anthem Multi-plan SummaryPDF versionText only version

CHEIBA Booklet 2017 by Section
Benefit Plan ContactsPDF versionText only version
IntroductionPDF versionText only version
Benefit EligibilityPDF versionText only version
Benefit HighlightsPDF versionText only version
Medical InsurancePDF versionText only version
Dental InsurancePDF versionText only version
Vision InsurancePDF versionText only version
Basic Term Life InsurancePDF versionText only version
Voluntary Term Life Insurance and AD&DPDF versionText only version
Flexible Benefit PlanPDF versionText only version
Long Term Disability InsurancePDF versionText only version
Employee Assistance ProgramPDF versionText only version
Travel Accident InsurancePDF versionText only version
Glossary of TermsPDF versionText only version
Legal NoticesPDF versionText only version

Summary of Benefits and Coverage
Blue Priority HMO PlanPDF versionText only version
HMO/Point of Service PlanPDF versionText only version
Prime Blue Priority PPO PlanPDF versionText only version
Custom Plus PlanPDF versionText only version
Lumenos HSA PlanPDF versionText only version


2016 CHEIBA Documents
CHEIBA Booklet 2016PDF versionText only version
2016 Rate SheetPDF versionText only version



 

 

 

 

 

 

 

 

 

 

 

 


 

CHEIBA Links CHEIBA Well-Being/Wellness Flyers
Anthem Website and Physician Locator
Participant Advocate Link (PAL)PDF versionText only version

CHEIBA Information
COBRA NoticePDF versionText only version
Medicare Part D NoticePDF versionText only version
 

Anthem Flu Shot InformationPDF versionText only version
Emergency CarePDF versionText only version
24/7 Nurse LinePDF versionText only version
Who Gets DiabetesPDF versionText only version
High Cholesterol Overview
Cholesterol Lowering FoodsPDF versionText only version