Benefit Forms

COBRA Member Handout

COBRA Member Handout.pdf 316.08 KB (Last Modified on July 6, 2022)

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Cobra Continuation of Coverage Monthly Insurance Rates 2023-2024

Cobra Rates 2023-2024.pdf 107.42 KB (Last Modified on April 18, 2023)

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Cobra Continuation of Coverage Monthly Insurance Rates 2024-2025

2024-2025 Cobra Rates.pdf 245.52 KB (Last Modified on April 10, 2024)

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Life Insurance Beneficiary Form

BeneficiaryDesignationFormSept20212.pdf 184.57 KB (Last Modified on July 6, 2022)

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Long Term Disability Information and Enrollment Form

UNUM_LTDHighlightandEnrollment2.pdf 578.83 KB (Last Modified on July 6, 2022)

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Medicare Credible Coverage

Creditable Coverage Disclosure Notice_2023.pdf 220.19 KB (Last Modified on October 5, 2022)

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Claim Forms

Employees who wish to receive matching payments for the wellness initiatives available through DVHT should complete the steps outlined in the DVHT Wellness Benefits Overview and then submit proof of payment/reimbursement from DVHT by uploading the needed documentation in this form: Delaware Valley Health Trust (DVHT) Wellness Initiatives Matching Google Form

United Group Flexible Spending Claim Form

Updated FSA Claim Form.pdf 598.83 KB (Last Modified on October 4, 2022)

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Flexible Spending Account Benefits

Flexible Spending Account Benefits.pdf 273.48 KB (Last Modified on July 6, 2022)

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Optimed Flexible Spending Plan Consumer Portal Quick Start Guide

Optimed Consumer Portal Quick Start Guide.pdf 307.65 KB (Last Modified on July 6, 2022)

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United Concordia Claim Form

United Concordia Claim Form2.pdf 819.63 KB (Last Modified on July 6, 2022)

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Delta Dental Claim Form

Delta Dental Claim Form2.pdf 152.07 KB (Last Modified on July 6, 2022)

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Long Term Disability Claim Information

UNUMDisabilityClaimInformation.pdf 189.88 KB (Last Modified on July 6, 2022)

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Long Term Disability Claim Form

LTD Claim Form-Unum.pdf 1.06 MB (Last Modified on September 14, 2022)

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Open Choice® - PPO $10/$20

202401 Pennsbury SD - SBC - PPO10-20.pdf 846.92 KB (Last Modified on October 26, 2023)

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Open Choice® - PPO $20/$20

202401 Pennsbury SD - SBC - PPO20.pdf 843.27 KB (Last Modified on October 26, 2023)

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Open Choice® - PPO $20/$40

202401 Pennsbury SD - SBC - PPO20-40.pdf 847.44 KB (Last Modified on October 26, 2023)

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Open Choice® - PPO $10/$20 RX $15/$30/$50

202401 Pennsbury SD - SBC - PPO10-20 RX15-30-50.pdf 855.13 KB (Last Modified on October 26, 2023)

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Open Choice® - PPO $20/$20 RX $15/$30/$50

202401 Pennsbury SD - SBC - PPO20 RX15-30-50.pdf 853.29 KB (Last Modified on October 26, 2023)

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Open Choice® - PPO $20/$40 RX $15/$30/$50

202401 Pennsbury SD - SBC - PPO20-40 RX15-30-50.pdf 855.45 KB (Last Modified on October 30, 2023)

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QPOS® - QPOS $30/$40

202401 Pennsbury SD - SBC - QPOS30-40.pdf 834.47 KB (Last Modified on October 26, 2023)

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QPOS® - QPOS $30/$40 RX $15/$30/$50

202401 Pennsbury SD - SBC - QPOS30-40 RX15-30-50.pdf 842.9 KB (Last Modified on October 26, 2023)

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Standalone Pharmacy – RX $15/$30/$50

202401 Pennsbury SD - SBC - Standalone RX15-30-50_.pdf 813.37 KB (Last Modified on October 26, 2023)

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