Forms

Available here is nearly every claim, enrollment and change form necessary to administer our benefit programs.  Please visit frequently as these forms may change.  If you are not able to locate an appropriate form, please Contact Us. You can also request a supply of selected forms by completing and submitting the online Supply Request form.

These forms are in a PDF format.  You will need the Adobe Acrobat Reader to view any of the documents.  If you do not have the Acrobat Reader, please visit the Adobe website, where you can download the free software.

Claim Forms | Enrollment Forms

Supply Request Form | Customer Feedback Form

Benefit Summary Pages

Need a quick overview of benefits? The benefit summaries are perfect for a glance of coverage levels. Just click to download, view or print as many copies as you need. You will need the Adobe Acrobat Reader to view these files. Contact Us with any questions.

Highmark Blue Shield PPO Benefit

• Highmark Preventive Care–2011 Covered Services Schedule
• Highmark Preventive Care–Grandfathered Plans Covered Services
 

Prescription Drug plans are creditable according to the Centers for Medicare and Medicaid Services guidelines. For more information regarding creditable coverage, please download and review the Creditable Coverage Information sheet.

Highmark Health Insurance Company Benefit Summaries

Dental Summaries & Booklets:

• Dental Network Summary (includes all plans)
• Dental Network Protect-A-Dent Premier 2 Booklet
• Dental Network Protect-A-Dent Premier 4 Booklet
• Dental Network Protect-A-Dent Select 2 Booklet
• Dental Network Protect-A-Dent Select 4 Booklet
• United Concordia Basic Dental Summary
• United Concordia Basic Dental Booklet
• United Concordia Premier Dental Summary
• United Concordia Premier Dental Booklet

Vision Summaries and Booklets:

• Davis Vision Value Vision Summary
• Davis Vision Value Vision Booklet
• Davis Vision Standard Vision Summary
• Davis Vision Standard Vision Booklet
• Davis Vision Crystal Vision Summary
• Davis Vision Crystal Vision Booklet
• NVA Fixed Insured Options Summary
• NVA Fixed Insured Options Booklet
• NVA Opti Vision Plus Summary
• NVA Opti Vision Plus Booklet
• NVA Opti-Vision Summary
• NVA Opti-Vision Booklet

Guardian Life and Disability Summaries and Booklets:

• Guardian Basic Life/AD&D Life Benefit Guide
• Benefits for Existing Businesses (Prior 1.1.05)
• Guardian Life
ooooo Plan A (Standard $20,000)
ooooo Plan B (Multiple of Salary)
ooooo Plan C (Flat Amount other than Standard)
ooooo Plan D (Flat Amount other than Occupation
ooooo Guardian Life Plan E (Group5Select Standard
          $15,000)
ooooo Basic Life/AD&D Life Benefit Guide
ooooo Basic Life/AD&D Life Benefit Guide 1.1.05
oooo
• Guardian Life (Disability Coverages)
(Coverage effective 8.1.06)
ooooo Short Term Disability Benefit Guide
ooooo Long Term Disability Benefit Guide
• Guardian Short Term Disability Certificates
ooooo Plan D3
ooooo Plan D4
ooooo Plan D5
ooooo Plan D6
ooooo Plan D7
ooooo Plan D8
ooooo Plan D9
ooooo Plan D10
ooooo Plan D11
ooooo Plan D12
ooooo Plan D13
ooooo Plan D15
• Guardian Long Term Disability Certificates
ooooo Plan D16
ooooo Plan D17
ooooo Plan D19
ooooo Plan D20
ooooo Plan D21
ooooo Plan D22
ooooo Plan D23

Other Benefit Summaries, Booklets and Useful Information:

• American Sentinel Part time Employee Benefit Program Brochure