PINC Region license # 0747420

Employer Forms

General

• 2008 PINC Member Participation Agreement and Group Information (Form # ER-01.1)
• 2008 Group Benefits Brochure
• 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

Worker's Compensation

• Brochure - Important Changes in California Workers’ Compensation
• Major changes in California's Worker's Compensation
• Facts About California's Worker's Compensation
• Facts About California's Worker's Compensation (in Spanish)
• Supervisor's Accident Investigation Report
• Worker's Compensation Reporting Form

Employee forms/Documents

Health Insurance Plans
Blue Shield

• Blue Shield - HMO Enrollment/Change Form (Form # EE-BS-01)
• 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

07 Blue Shield Benefit Summaries Active Choice 750 Active Choice 500 HMO 5 HMO 10 HMO 15 HMO 20 HMO 25 HMO 40 PPO Zero PPO 250 Standard PPO 250 Premier PPO 500 Standard PPO 500 Premier PPO 500 Value PPO 1000 PPO 1000 Value PPO 1500 PPO 3000 PPO 2250 PPO 2600 POS 500

08 Blue Shield Benefit Summaries Active Choice 750 Active Choice 500 HMO 5 HMO 10 HMO 15 HMO 20 HMO 25 HMO 40 PPO Zero 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 PPO 2250 PPO 2500 Advantage POS

07 Blue Shield Evidence of Coverages Active Choice 500 Active Choice 500 RX Active Choice 750 Active Choice 750 RX POS Advantage POS Advantage RX HMO 5 HMO 5 RX HMO 10 HMO 10 RX HMO 15 HMO 15 RX HMO 20 HMO 20 RX HMO 25 HMO 25 RX HMO 40 HMO 40 RX PPO 250 Premier PPO 250 Premier RX PPO 250 Standard PPO 250 Standard RX PPO 500 Premier PPO 500 Premier RX PPO 500 Standard PPO 500 Standard RX PPO 500 Value PPO 500 Value RX PPO 1000 PPO 1000 RX PPO 1000 Value PPO 1000 Value RX PPO 1500 Value PPO 1500 Value RX PPO 2250 PPO 2600 PPO 3000 PPO 3000 RX PPO Zero

08 Blue Shield Evidence of Coverages Active Choice 500 Active Choice 750 POS Advantage HMO 5 HMO 10 HMO 15 HMO 20 HMO 25 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

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 - Commercial Member Claim Form
• HealthNet - Prescription Claim Form
• HealthNet (PHI) Protected Health Information HIPAA Authorization Form
• HealthNet RX Mail-order Program

07 HealthNet Benefit Summaries EOA 10 EOA 25 EOA 30 HMO 15 HMO 20 HMO 35 HMO 40 POS 20 POS 30 PPO 15 PPO 20 PPO 30 PPO 40 PPO 2000 PPO 3000	08 HealthNet Benefit Summaries EOA 10 EOA 20 EOA 30 EOA Value 10 EOA Value 20 EOA Value 30 HMO 20 HMO 40 Value HMO 20 Value HMO 40 POS 20 HSA PPO 20 HSA PPO 30 HSA PPO 40 PPO 20 PPO 30 PPO 40 Value PPO 20 Value PPO 30 Value PPO 40
07 HealthNet Evidence of Coverage Elect 10 Elect 25 Elect 30 HMO 15 HMO 20 HMO 35 HMO 40 HSA 2000 HSA 3000 POS 20 POS 30 PPO 15 PPO 20 PPO 30 PPO 40	08 HealthNet Evidence of Coverage Elect 10 Elect 30 EOA Value 10 EOA Value 20 EOA Value 30 HMO 20 HMO 40 Value HMO 20 Value HMO 40 POS 20 HSA PPO 20 HSA PPO 30 HSA PPO 40 PPO 20 PPO 30 PPO 40 Value PPO 20 Value PPO 30 Value PPO 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

07 Kaiser Benefit Summaries HMO 5 HMO 10 HMO 15 HMO 20 HMO 25 HMO 30 500/10 500/20 1000/20 2700	08 Kaiser Benefit Summaries HMO 5 HMO 10 HMO 15 HMO 20 HMO 25 HMO 30 HMO High Copay 40 500/10 500/20 1000/20 HSA 1500
07 Kaiser Evidence of Coverage 500 Deductible 10 500 Deductible 20 1000 Deductible 20 HMO 5 HMO 10 HMO 15 HMO 20 HMO 25 HMO 30 HSA 2700	08 Kaiser Evidence of Coverage 500 Deductible 10 500 Deductible 20 1000 Deductible 20 HMO 5 HMO 10 HMO 15 HMO 20 HMO 25 HMO 30 HMO 40 High Copay HSA 1500

CIGNA

• CIGNA - HMO Enrollment/Change Form (Form # EE-CG-01)
• CIGNA (PHI) Protected Health Information HIPAA Authorization Form
• CIGNA RX Mail-order Program

07 CIGNA Benefit Summaries HMO 15 HMO 30	08 CIGNA Benefit Summaries HMO 20 HMO 30
07 CIGNA Evidence of Coverage HMO 15 HMO 30

Other Plans

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

Dental

• Dental Enrollment/Change Form for all plans (Form # EE-DN-01)
• Dental Enrollment/Change Form for Humana (Form # EE-DN-02)
• Dental Enrollment/Change Form for Humana (in Spanish) (Form # EE-DN-02s)
• Blue Shield Dental (PHI) Protected Health Information HIPAA Authorization Form
• CIGNA Dental (PHI) Protected Health Information HIPAA Authorization Form
• SafeGuard Dental (PHI) Protected Health Information HIPAA Authorization For
• SafeGuard Dental Claim Form

Dental Plan Benefit Summaries Blue Shield DMO CIGNA DMO F1-06 Safeguard DMO Safeguard DPO Western Dental 830WN4 Western Dental CALW4

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 Chiro w/Acu Chiro only

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 Comprehensive

08 MHN Evidence of Coverage 08 MHN EOC

Life Insurance

• Voluntary/Traditional Term Life Group Enrollment form
• Voluntary/Traditional Term Life Statement of Insurability
• Voluntary Term Life Coverage Benefit Options (SC)
• Voluntary Term Life Coverage Benefit Options (SD)
• Voluntary Term Life Conversion Form
• Voluntary Term Life Beneficiary Form



• Voluntary/Traditional Life Waiver of Premium
• Voluntary/Traditional Life Proof of Death
• Voluntary Term Life Summary of Plan Description
• Traditional Term Life Summary of Plan Description



• Basic Group Life Summary of Plan Description
• Basic Group Life Waiver of Premium
• Basic Group Life Proof of Death
• Basic Group Life Beneficiary Form

Certificates of Insurance VTL 25-250k

Miscellaneous Forms

• Full Time Student Certification Form (Form # EE-ST-01)

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	www.kaiserpermanente.org
DENTAL
Blue Shield Dental	(800) 585-8111	www.blueshieldca.com
Cigna Dental	(800) 367-1037	www.cigna.com
Safeguard DMO Dental	(800) 880-1800	www.safeguard.net
Safeguard DPO Dental	(800) 962-9633	www.safeguard.net
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
Comprehensive Mental Health	(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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