EGYPTIAN AREA SCHOOLS EMPLOYEE BENEFIT TRUST
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Employee Forms

• Enrollment Form - All ProductsUpdated 1/12
• Enrollment Form - Changes OnlyUpdated 1/12
• Enrollment Notice - 12 month notice to change health plan
• Dependent Status Form
• Member Statements Form
• MyMeritain Member Website

Medical Plans

• HIPAA Privacy Practices
• Schedule of Benefits - Platinum
• Schedule of Benefits - Gold
• Schedule of Benefits - Silver
• Schedule of Benefits - Bronze
• 2011 Preventive Drug List – Bronze Plan Only
• 2011 Drug Formulary

Dental

• Dental Summary of Benefits-HIGH PLAN
• Dental Summary of Benefits-LOW PLAN
  
  

Employer Forms

• Employer - Individual Selection Form (must be completed every August 1st)
• Employer - Contact Change Form

Claim Forms

• Medical Claim Form
• Prescription Drug Claim Form

Vision

• Summary of Benefits � Vision
• Vision Out of Network Claim Form
• UniView Vision Benefits Brochure
• Healthy Extensions Flyer

Life Insurance

• Optional Life Insurance Brochure
• Life Claim Form
• Extension Of Death Benefits Application

The Evidence of Insurability (EOI) form is to be completed when an employee or spouse is enrolling for more than the guaranteed issue amount. Guaranteed issue amount is $75,000 for new employees under age 60 when enrolling within 31 days of their date of hire. Guaranteed issue amount for a spouse is 50% of the employee’s election up to $25,000 when enrolling within 31 days of the employees date of hire.

Evidence of Insurability

The Continuation Provision allows employees to keep their Life Insurance coverage when they leave your School District. This provision offers a rate that is closer to the current group rate than the Conversion Provision. Employees who have had coverage for at least 12 months and are leaving the district for something other than an injury, retirement, or sickness would be eligible to apply for the Continuation Provision.

Continuation of Coverage

The Conversion Provision allows employees to keep their Life Insurance coverage when they leave your School District. This provision can be used for any type of termination and employees that have been covered under the plan are eligible. This provision does not require 12 prior months of coverage. Please call Lincoln Financial Group at 800-423-2765 for a quote. You will need to reference group ID EGYPTIAN.

Conversion of Coverage

The Change of Beneficiary Form is to be used when an employee wishes to change a beneficiary, contingent beneficiary, or designated percentage of benefit. Employers should retain a copy in the employee's personnel file and also send a copy to Lincoln Financial Group as indicated on the form.

Change of Beneficiary Form