(Open Enrollment Dates: November11 – December 12, 2011) All employees eligible for benefits MUST complete a Benefits Enrollment Form for 2012 (electronic form accessible through MYFranciscan employee login; or see Human Resources for a paper form) Reference Materials: Highmark BCBS HealthInsurance Coverage - Core Grid Highmark BCBS HealthInsurance Coverage – Buy-Up Grid Highmark Blue CrossBlue Shield Enrollment Application Highmark Blue CrossBlue Shield Member Change Form Davis Vision Plan Grid Affidavit to Add aNon-Dependent Child under the age of 26 United Concordia Voluntary Dental Plan - Core GridUnited Concordia Voluntary Dental Plan -Buy-up Grid Unum Voluntary Life/ADD Program – Plan HighlightsUnum Life/ADD CalculatorUnum Life/ADD Enrollment FormUnum Evidence of Insurability Form HRA Schedule for 2012 Disclosures: Notice of Opportunity to Enroll Extension of Dependent Coverage to Age 26 Grandfathered Health Plan Disclosure Notice Notice of Continuation of Coverage Rights Under COBRA Notice of Prescription Drug Coverage and Medicare Notice of Women’s Health and Cancer Right Act of 1998 (WHCRA)
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