EGYPTIAN AREA SCHOOLS
EMPLOYEE BENEFIT TRUST
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Employee Forms
Enrollment Form - All Products
Updated 7/7/10
Enrollment Form - Changes Only
Updated 7/7/10
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
2010 Preventive Care Drug Listing - Bronze
2010 Drug Formulary
Dental
Dental Summary of Benefits
Employer Forms
Employer - Individual Selection Form (must be completed every August 1st)
Employer - Contact Change Form
Claim Forms
Dental Claim Form
Medical Claim Form
Prescription Drug Claim Form
Life Insurance
Optional Life Insurance Brochure
Evidence of Insurability Form
Life Claim Form
Group Life Conversion Brochure
Continuation of Coverage Form
Portability Application
Extension Of Death Benefits Application
Vision
Summary of Benefits � Vision
Vision Out of Network Claim Form
UniView Vision Benefits Brochure
Healthy Extensions Flyer
