Other Forms

2012 ProtectPlus Plans

2012 EZ Guide
2012 Simplified Plan Comparison Chart for Firms of 2+
2012 Simplified Plan Comparison Chart for Solo Practitioners

2012 ProtectPlus Individual Plan Brochures
Protect 10
Protect 15
Protect 25
Protect 35
Protect 40
Protect 45
Protect HSA 1500
Protect HSA 2500
Protect HSA 2850
Protect HSA 3500
2011 Anthem Blue Cross HMO Advantage 100
2011 Anthem Blue Cross HMO Value 80

Summary Plan Descriptions (SPD's)

Please note: The benefits under the Grandfathered plans and the Non-Grandfathered plans are the same. The only difference in the SPDs is that the Grandfathered plans contain an additional disclosure on page 2.

2011 Grandfathered Plans
Protect 10
Protect 15
Protect 25
Protect 35
Protect 45
HSA 1500
HSA 2500
HSA 2850
HMO Advantage 100
HMO Value 80

2011 Non-Grandfathered Plans
Protect 10
Protect 15
Protect 25
Protect 35
Protect 45
HSA 1500
HSA 2500
HSA 2850
HMO Advantage 100
HMO Value 80

Please Note: The Summary Plan Description for each benefit design and the related rate filings filed with the California Department of Insurance for each design constitute the Group Insurance Trust Rating Manual.  The Rating Manual contains information sufficient to verify that ProtectPlus and related dental and vision plans satisfy the requirements of Section 419A(f)(6).  The trustees are required to maintain a record of the Rating Manual for all years of operations.  Upon written request addressed to the Trustees of the Group Insurance Trust, a participating employer, the representative of a participating employer, or the Commissioner of Internal Revenue may obtain access to view and copy any such records.

New! Personal Health Record Form
(Note: This is not a legal document and should be considered a helpful tool in communicating with your physicians and family.)
Personal Health Record

HSA Forms and Information
Alliant - Bank of New York Mellon - US Bank Fee Comparison
HSA Q&A
Alliant Credit Union HSA FAQs
Mellon - US Bank Investment Options Comparison
Mellon/US Bank Employer Set Up Form
US Bank Product Guide

Miscellaneous Forms and Information

Open Enrollment Change Report
Employee/Subscriber Change Form
Disabled Dependent Certification Form
Domestic Partner Information & Affidavit
Automatic Payment Authorization
COBRA/CalCOBRA Notice and Notification Form
Terminated Employee Form

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