Forms for Download

 
 
 
 
 
 

Disclosures of Creditable Coverage

2016 Creditable Letter and Disclosure

2017 Benefit Highlight Sheets

1000 PPO Plan

1500 PPO Plan

2500 PPO Plan

3000 PPO Plan

3000 High Deductible Health Plan

4500 PPO Plan

2500 Blue Value POS (Available in North Idaho Only)

Employee Assistance Program (EAP)

Delta Dental

Vision Plan Benefits

Summary Plan Descriptions (SPD)

1000 PPO Rx 1 Plan SPD

1000 PPO Rx 2 Plan SPD

1500 PPO Rx 1 Plan SPD

1500 PPO Rx 2 Plan SPD

2500 PPO Rx 1 Plan SPD

2500 PPO Rx 2 Plan SPD

2500 Blue Value Rx 1 Plan SPD (Available in North Idaho only)

2500 Blue Value Rx 2 Plan SPD (Available in North Idaho only)

3000 PPO Rx 1 Plan SPD

3000 PPO Rx 2 Plan SPD

3000 High Deductible SPD

4500 PPO Rx 1 Plan SPD

4500 PPO Rx 2 Plan SPD

 

Plan Comparison Summary

2017 Basic Plan Comparison

2017 Deluxe Plan Comparison

2017 Blue Value Basic & Deluxe Comparison

2017 Notice of Plan Changes

PPO Plans

High Deductible Health Plan

Broker/Agency Forms

Census Form

Waiver of Coverage

Group Quote Checklist

Idaho Universal Group Application & Addendum

Sold Group Checklist

Medical and Prescription Drug Forms

Blue Cross of Idaho Claim Form

Prescription Drug Claim Form

Lincoln National Life, STD, and Accident Coverage

Enrollment Form

Optional Life Summary

Short Term Disability Summary

STD Buy-Up Rates - Class 1

STD Buy-Up Rates - Class 2

Term Life and AD&D Summary

Accident Summary

Employer Applications

Idaho Universal Group Application & Addendum

Employer Forms

Leave of Absence Request

Self-Termination of Employee or Dependent Form

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