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PIASC and PIASD

Employer Forms

General

• 2012 Member Participation Agreement and Group Information for Southern California (Form # ER-01)
• 2012 Member Participation Agreement and Group Information for San Diego (Form # ER-01)
• 2012 Group Benefits Brochure for Southern California
• 2012 Group Benefits Brochure for San Diego
• Group Administrative Guidelines (Form # ER-02)
• Section 125 Cafeteria Plan Document (Form # ER-04)
• Section 125 Employee Salary Reduction Form (Form # ER-05)
• Employee Termination/Waive/Decline Coverage Form (Form # ER-06)
• California Domestic Partnership Declaration Form
• California Domestic Partnership Termination Form
• Change of Address Form
• 2009 HIPAA Notice
• 2010 HSA Plans Administrative Regulations

COBRA information

• An Employee's Guide to CAL-COBRA Health Benefits Continuation
• An Employee's Guide to Health Benefits Under COBRA

Worker's Compensation

State Compensation Insurance Fund ™

State Compensation Insurance Fund ™ State Compensation Insurance Fund provides workers' compensation insurance to employers in California. Its services include claims services, claims management service, medical network, policy services, loss control services, medical cost management services. The company was founded in 1914 and is based in San Francisco, California.
Link to official site: www.scif.com

• Workers’ Compensation Brochure

Workers' Compensation Claim Forms Berkshire Hathaway Homestate Companies Everest National Insurance Company First Comp Insurance Company Preferred Employers Insurance Company State Compensation Insurance Fund

Programs For Printers

• Directors and Officers Liability Insurance
• Employment Practices Liability
• Printers Errors and Omissions

Programs for Printers Hartford One Beacon Safeco Travelers Travelers for Packaging and Mailing

Employee forms/Documents

Health Insurance Plans
AETNA

• AETNA - HMO Enrollment/Change Form (Form # EE-A-01)
• AETNA - PPO Enrollment/Change Form (Form # EE-A-01)
• AETNA Medical Claim Form
• AETNA Medical Mail Order
• AETNA (PHI) Protected Health Information Authorization Form

08 AETNA Benefit Summaries HMO 500/40 PPO 2000/4000

08 AETNA Evidence of Coverage HMO 500/40 HMO 500/40 (San Diego) PPO 2000/4000

Blue Shield

• Blue Shield - HMO Enrollment/Change Form (Form # EE-BS-01)
• Blue Shield - Local HMO Enrollment/Change Form
• Blue Shield - POS Enrollment/Change Form (Form # EE-BS-02)
• Blue Shield - PPO Enrollment/Change Form(Form # EE-BS-03)
• Blue Shield - Active Choice Enrollment/Change Form (Form # EE-BS-04)
• Blue Shield - Subscribers Statement of Claim
• Blue Shield - Prescription Drug Direct Reimbursement Form
• Blue Shield International Claim Form
• Blue Shield (PHI) Protected Health Information HIPAA Authorization Form
• Blue Shield RX Mail-order Program
• Blue Shield Drug Formulary

2011 Blue Shield Benefit Summaries Active Choice 750 Active Choice 500 AccessPlus HMO 5 AccessPlus HMO 10 AccessPlus HMO 15 AccessPlus HMO 20 AccessPlus HMO 25 AccessPlus HMO 30 AccessPlus HMO 40 LOCAL ACCESS HMO 20 Value LOCAL ACCESS HMO 30 PPO Zero Deductible PPO 250 Standard PPO 250 Premier PPO 500 Standard PPO 500 Premier PPO 500 Value PPO 1000 PPO 1000 Value PPO 1500 Value PPO 3000 Spectrum PPO 2000 Value PPO Savings 2250 PPO Savings 2500 Savings QS 4800 Added Advantage POS

2012 Blue Shield Benefit Summaries Active Choice 750 Active Choice 500 AccessPlus HMO 5 AccessPlus HMO 10 AccessPlus HMO 15 AccessPlus HMO 20 AccessPlus HMO 25 AccessPlus HMO 30 AccessPlus HMO 40 LOCAL ACCESS HMO 20 Value LOCAL ACCESS HMO 30 PPO Zero Deductible PPO 250 Standard PPO 250 Premier PPO 500 Standard PPO 500 Premier PPO 500 Value PPO 1000 PPO 1000 Value PPO 1500 Value Spectrum PPO 2000 Value PPO 3000 PPO Savings 2250 PPO Savings 2500 Savings QS 4800 Added Advantage POS

2010 Blue Shield Evidence of Coverages Active Choice 500 Active Choice 750 POS Advantage HMO 5 HMO 10 HMO 15 HMO 20 HMO 25 HMO 30 HMO 40 PPO 250 Premier PPO 250 Standard PPO 500 Premier PPO 500 Standard PPO 500 Value PPO 1000 PPO 1000 Value PPO 1500 Value PPO SavingsPlan 2250 PPO SavingsPlan 2500 PPO 3000 PPO Zero

2011 Blue Shield Evidence of Coverages Active Choice 750 Active Choice 500 AccessPlus HMO 5 AccessPlus HMO 10 AccessPlus HMO 15 AccessPlus HMO 20 AccessPlus HMO 25 AccessPlus HMO 30 AccessPlus HMO 40 PPO Zero Deductible PPO 250 Standard PPO 250 Premier PPO 500 Standard PPO 500 Premier PPO 500 Value PPO 1000 PPO 1000 Value PPO 1500 Value PPO 3000 Spectrum PPO 2000 Value PPO Savings 2250 PPO Savings 2500 Savings QS 4800 Added Advantage POS

Healthnet

• HealthNet - HMO Enrollment/Change Form (Form # EE-HN-01)
• HealthNet - POS Enrollment/Change Form (Form # EE-HN-02)
• HealthNet - PPO Enrollment/Change Form (Form # EE-HN-03)
• HealthNet - EOA Enrollment/Change Form (Form # EE-HN-04)
• HealthNet - Silver HMO Enrollment/Change Form (Form # EE-HN-05)
• HealthNet - Bronze HMO Enrollment/Change Form (Form # EE-HN-06)
• HealthNet - Commercial Member Claim Form
• HealthNet - Prescription Claim Form
• HealthNet (PHI) Protected Health Information HIPAA Authorization Form
• HealthNet RX Mail-order Program
• HealthNet Drug Formulary

2011 HealthNet Benefit Summaries Silver Standard EOA 30 (SC only) Silver Value EOA 30 (SC only) Standard EOA 10 Standard EOA 30 EOA Value 10 EOA Value 20 EOA Value 30 Advantage HMO 25 Advantage HMO 35 Advantage HMO 45 Bronze Standard HMO 30 Bronze Standard HMO 40 Standard HMO 20 Standard HMO 40 Bronze Value HMO 30 Bronze Value HMO 40 Value HMO 20 Value HMO 40 POS 20 Value HSA PPO 2500 Value HSA PPO 3500 Value HSA PPO 4500 Standard PPO 20 Standard PPO 30 Standard PPO 40 Value PPO 20 Value PPO 30 Value PPO 40 Silver Advantage HMO 25 Silver Advantage HMO 35 Silver Advantage HMO 45 Silver HMO Standard 30 Silver HMO Standard 40 Silver HMO Value 30 Silver HMO Value 40

2012 HealthNet Benefit Summaries Silver Standard EOA 30 (SC only) Silver Value EOA 30 (SC only) Standard EOA 10 Standard EOA 30 EOA Value 10 EOA Value 20 EOA Value 30 Advantage HMO 25 Advantage HMO 35 Advantage HMO 45 Bronze Standard HMO 30 Bronze Standard HMO 40 Standard HMO 20 Standard HMO 40 Bronze Value HMO 30 Bronze Value HMO 40 Value HMO 20 Value HMO 40 POS 20 Value HSA PPO 2500 Value HSA PPO 3500 Value HSA PPO 4500 Standard PPO 20 Standard PPO 30 Standard PPO 40 Value PPO 20 Value PPO 30 Value PPO 40 Silver Advantage HMO 25 Silver Advantage HMO 35 Silver Advantage HMO 45 Silver HMO Standard 30 Silver HMO Standard 40 Silver HMO Value 30 Silver HMO Value 40

2010 HealthNet Evidence of Coverage EOA Value 10 EOA Value 20 EOA Value 30 Standard EOA 10 Standard EOA 30 Standard HMO 20 Standard HMO 40 Value HMO 20 Value HMO 40 POS 20 Value HSA PPO 2500 Value HSA PPO 3500 Standard PPO 20 Standard PPO 30 Standard PPO 40 Value PPO 40 Standard HMO 30 Silver Standard HMO 40 Silver Value HMO 30 Silver Value HMO 40 Silver

2011 HealthNet Evidence of Coverage Silver Standard EOA 30 (SC only) Silver Value EOA 30 (SC only) Standard EOA 10 Standard EOA 30 EOA Value 10 EOA Value 20 EOA Value 30 Advantage HMO 25 Advantage HMO 35 Advantage HMO 45 Bronze Standard HMO 30 Bronze Standard HMO 40 Standard HMO 20 Standard HMO 40 Bronze Value HMO 30 Bronze Value HMO 40 Value HMO 20 Value HMO 40 POS 20 Value HSA PPO 2500 Value HSA PPO 3500 Value HSA PPO 4500 Standard PPO 20 Standard PPO 30 Standard PPO 40 Value PPO 20 Value PPO 30 Value PPO 40 Silver Advantage HMO 25 Silver Advantage HMO 35 Silver Advantage HMO 45 Silver HMO Standard 30 Silver HMO Standard 40 Silver HMO Value 30 Silver HMO Value 40

Kaiser Permanente

• Kaiser - HMO Enrollment/Change Form (Form # EE-KP-01)
• Kaiser - Deductible HMO Enrollment/Change Form (Form # EE-KP-02)
• Kaiser (PHI) Protected Health Information HIPAA Authorization Form
• Kaiser RX Mail-order Program Brochure
• Kaiser RX Mail-order Program Forms only

2011 Kaiser Benefit Summaries HMO 10 HMO 15 HMO 20 HMO 25 HMO 30 HMO 40 HMO 50 500/10 500/20/20% 1000/20 HSA 1500 HSA 2000 Hospital Deductible 500/20/10% Hospital Deductible 1000/30 HMO 10 (San Diego only) HMO 15 (San Diego only) HMO 20 (San Diego only) HMO 25 (San Diego only) HMO 30 (San Diego only) HMO 40 (San Diego only) HMO 50 (San Diego only) 500/10 (San Diego only) 500/20/20% (San Diego only) 1000/20 (San Diego only) HSA 1500 (San Diego only) HSA 2000 (San Diego only) Hospital Deductible 500/20/10% (San Diego only) Hospital Deductible 1000/30 (San Diego only)

2012 Kaiser Benefit Summaries HMO 10 HMO 15 HMO 20 HMO 25 HMO 30 HMO 40 HMO 50 500/10 500/20/10% 1000/20 HSA 1500 HSA 2000 Hospital Deductible 500/20/10% Hospital Deductible 1000/30 Hospital Deductible 1500/40 Hospital Deductible 3000/40 HMO 10 (San Diego only) HMO 15 (San Diego only) HMO 20 (San Diego only) HMO 25 (San Diego only) HMO 30 (San Diego only) HMO 40 (San Diego only) HMO 50 (San Diego only) 500/10 (San Diego only) 500/20/20% (San Diego only) 1000/20 (San Diego only) HSA 1500 (San Diego only) HSA 2000 (San Diego only) Hospital Deductible 500/20/20% (San Diego only) Hospital Deductible 1000/30 (San Diego only) Hospital Deductible 1500/40 (San Diego only) Hospital Deductible 3000/40 (San Diego only)

2010 Kaiser Evidence of Coverage 500 Deductible 10 500 Deductible 10 (San Diego) 500 Deductible 20 500 Deductible 20 (San Diego) 1000 Deductible 20 1000 Deductible 20 (San Diego) 1500 Deductible HSA 100 1500 Deductible HSA 100 (San Diego) HMO 10 HMO 10 (San Diego) HMO 15 HMO 15 (San Diego) HMO 20 HMO 20 (San Diego) HMO 25 HMO 25 (San Diego) HMO 30 HMO 30 (San Diego) HMO 40 High Copay HMO 40 High Copay (San Diego) 500 Deductible 20 Hospital 500 Deductible 20 Hospital (San Diego) 1000 Deductible 30 Hospital 1000 Deductible 30 Hospital (San Diego) 2000 Deductible 30 HSA 2000 Deductible 30 HSA (San Diego)

2011 Kaiser Evidence of Coverage HMO 10 HMO 15 HMO 20 HMO 25 HMO 30 HMO 40 HMO 50 500/10 500/20/20% 1000/20 HSA 1500 HSA 2000 Hospital Deductible 500/20/10% Hospital Deductible 1000/30 HMO 10 (San Diego) HMO 15 (San Diego) HMO 20 (San Diego) HMO 25 (San Diego) HMO 30 (San Diego) HMO 40 (San Diego) HMO 50 (San Diego) 500/10 (San Diego) 500/20/20% (San Diego) 1000/20 (San Diego) HSA 1500 (San Diego) HSA 2000 (San Diego) Hospital Deductible 500/20/10% (San Diego) Hospital Deductible 1000/30 (San Diego)

 

Other Plans

Executive Benefit Option

• Employer Brochure (Form # ER-EX-01)
• Summary Plan Description
• New Group Summary and Application (Form # ER-EX-02)
• Enrollment/Change Form (Form # ER-EX-03)
• Claim Form

Dental

Enrollment/Change forms

• All plans (Form # EE-DN-01)
• Humana custom plans (Form # EE-DN-02)
• Humana custom plans(in Spanish) (Form # EE-DN-02s)

HIPAA Authorization form for Protected Health Information

• Blue Shield
• CIGNA
• Humana

Dental Claim Form

• Humana PPO

Dental Plan Benefit Summaries Blue Shield DMO CIGNA DMO W1-07 Humana DPO SC Humana SPD SC Humana Preferred Choice DMO Western Dental 7740 Western Dental 7750

Vision

• Vision Enrollment/Change Form for all plans (Form # EE-VS-01)
• Vision Claim Form
• EyeMed Out-of-Network Claim Form
• VSP Out-of-Network Claim Form
• VSP (PHI) Protected Health Information HIPAA Authorization Form

Vision Plans Benefit Summaries EyeMed Indemnity VSP I VSP II

Chiropractic

• Chiropractic Enrollment/Change Form for all plans (Form # EE-CH-01)

Chiropractic Plans Benefit Summaries Chiropractic w/Acupuncture Chiropractic Basic

Mental Health

• Mental Health Enrollment/Change Form for all plans (Form # EE-MH-01)
• Mental Health (PHI) Protected Health Information HIPAA Authorization Form

Mental Health Plans Benefit Summaries Employee Assistance Program

2012 MHN Evidence of Coverage MHN EOC

Life Insurance

Voluntary Term Life

• Group Enrollment form
• Statement of Insurability
• Coverage Benefit Options
• Conversion Form
• Beneficiary Form
• Waiver of Premium
• Proof of Death
• Voluntary Term Life Summary of Plan Description
• Traditional Term Life Summary of Plan Description

Certificates of Insurance VTL 25-250k

Basic Group Life

• Summary of Plan Description
• Waiver of Premium
• Proof of Death
• Beneficiary Form
• Conversion Form
• Death Benefits

Certificates of Insurance Basic Group Life SC_SD 4k-10k

TASC Flexible Saving Account

• Flex System Advantages
• Flex System Eligible Expenses
• Group Plan Application
• Flex System Individual Application

Health Care Provider Links

MEDICAL
Blue Shield HMO & PPO	(888) 235-1765	www.blueshieldca.com
Cigna Healthcare	(800) 244-6224	www.cigna.com
HealthNet HMO & PPO	(800) 361-3366	www.healthnet.com
Kaiser	(800) 464-4000	http://my.kp.org/pibt/index.html
DENTAL
Blue Shield Dental	(800) 585-8111	www.blueshieldca.com
Cigna Dental	(800) 367-1037	www.cigna.com
Humana DPO Dental	(800) 233-4013	www.humanadental.com
Humana DMO (GoldenWest)	(888) 200-5022	www.humanadental.com
Western Dental	(800) 992-3366	www.westerndental.com
VISION
EyeMed Vision Care	(866) 939-3633 option 6	www.eyemedvisioncare.com
PIA Indemnity Vision	(323) 728-9500
VSP I & VSP II	(800) 877-7195	www.vsp.com
CHIROPRACTIC
Landmark	(800) 638-4557	www.landmarkhealthcare.com
MENTAL HEALTH
Employee Assistant Program EAP	(800) 777-9355	www.members.mhn.com

Other Regions

Forms are tailored by region:

For an evaluation of your insurance coverage today, please call the Insurance Department at (323) 728-9500.

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Insurance Page

PIASC and PIASD Region license #0747420

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All Content © 2010 Printing Industries Association, Inc. of Southern California
5800 S. Eastern Avenue, Suite 400, Los Angeles, CA 90040 | FAX (323) 724-2327 | info@piasc.org
Phone: (323) 728-9500 or 808-9990 for area codes: 213, 310, 619, 714, 818, & 951