[et_pb_section fb_built=”1″ custom_padding_last_edited=”on|desktop” admin_label=”section” _builder_version=”4.16″ background_color=”#ededed” custom_padding_tablet=”50px|0|50px|0″ custom_padding_phone=”” transparent_background=”off” padding_mobile=”off” global_colors_info=”{}”][et_pb_row padding_mobile=”off” column_padding_mobile=”on” admin_label=”row” _builder_version=”4.16″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text admin_label=”Forms” _builder_version=”4.16″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” use_border_color=”off” border_color=”#ffffff” border_style=”solid” global_colors_info=”{}”]<\/p>\n
[\/et_pb_text][et_pb_tabs active_tab_background_color=”#19a3dd” admin_label=”Tabs wCoverage Info” _builder_version=”4.25.1″ tab_font_size=”12″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” hover_enabled=”0″ use_border_color=”off” global_colors_info=”{}” sticky_enabled=”0″][et_pb_tab title=”Benefit Election\/Change Forms” _builder_version=”4.24.1″ body_font=”||||” body_line_height=”2em” tab_font=”||||” tab_line_height=”2em” body_line_height_tablet=”2em” body_line_height_phone=”2em” tab_line_height_tablet=”2em” tab_line_height_phone=”2em” global_colors_info=”{}”]<\/p>\n
Please submit completed forms to the Human Resources Department for processing.<\/p>\n
[\/et_pb_tab][et_pb_tab title=”Medical” _builder_version=”4.24.1″ body_font=”||||” body_line_height=”2em” tab_font=”||||” tab_line_height=”2em” body_line_height_tablet=”2em” body_line_height_phone=”2em” tab_line_height_tablet=”2em” tab_line_height_phone=”2em” global_colors_info=”{}”]<\/p>\n
Anthem Medical Claim Form<\/a> Click here to be re-directed to the Medical Benefits page.<\/a><\/p>\n [\/et_pb_tab][et_pb_tab title=”Dental” _builder_version=”4.24.1″ body_font=”||||” body_line_height=”2em” tab_font=”||||” tab_line_height=”2em” body_line_height_tablet=”2em” body_line_height_phone=”2em” tab_line_height_tablet=”2em” tab_line_height_phone=”2em” global_colors_info=”{}”]<\/p>\n Direct Dental Claim Form<\/a><\/p>\n Click here to be re-directed to the Dental Benefits page.<\/a><\/p>\n [\/et_pb_tab][et_pb_tab title=”Vision” _builder_version=”4.24.1″ body_font=”||||” body_line_height=”2em” tab_font=”||||” tab_line_height=”2em” body_line_height_tablet=”2em” body_line_height_phone=”2em” tab_line_height_tablet=”2em” tab_line_height_phone=”2em” global_colors_info=”{}”]<\/p>\n VSP Vision Claim Form<\/a> [\/et_pb_tab][et_pb_tab title=”FSA” _builder_version=”4.25.1″ body_font=”||||” body_line_height=”2em” tab_font=”||||” tab_line_height=”2em” hover_enabled=”0″ body_line_height_tablet=”2em” body_line_height_phone=”2em” tab_line_height_tablet=”2em” tab_line_height_phone=”2em” global_colors_info=”{}” sticky_enabled=”0″]<\/p>\n FSA Claim Form<\/a> [\/et_pb_tab][et_pb_tab title=”Retirement” _builder_version=”4.24.1″ body_font=”||||” body_line_height=”2em” tab_font=”||||” tab_line_height=”2em” body_line_height_tablet=”2em” body_line_height_phone=”2em” tab_line_height_tablet=”2em” tab_line_height_phone=”2em” global_colors_info=”{}”]<\/p>\n 457 Plan – How To Enroll Online<\/a> Click here to be re-directed to the Retirement Benefits page. [\/et_pb_tab][et_pb_tab title=”Other Forms” _builder_version=”4.24.1″ body_font=”||||” body_line_height=”2em” tab_font=”||||” tab_line_height=”2em” body_line_height_tablet=”2em” body_line_height_phone=”2em” tab_line_height_tablet=”2em” tab_line_height_phone=”2em” global_colors_info=”{}”]How to Obtain Reimbursement:<\/p>\n To obtain reimbursement for any of these benefits, employees must submit a Benefits Expense Reimbursement Form<\/span><\/a> on SharePoint, along with receipt\/proof of payment to the Payroll Department. Pre-Paid Legal Services Membership Application<\/a> Forms Please submit completed forms to the Human Resources Department for processing.Anthem Medical Claim FormAnthem Pharmacy Reimbursement Claim FormAnthem Mail Order Pharmacy Reimbursement Claim Form Click here to be re-directed to the Medical Benefits page.Direct Dental Claim Form Click here to be re-directed to the Dental Benefits page.VSP Vision Claim FormClick here to be re-directed […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":7,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-133","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/mybenefits.cc\/alliance\/wp-json\/wp\/v2\/pages\/133","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mybenefits.cc\/alliance\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mybenefits.cc\/alliance\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mybenefits.cc\/alliance\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mybenefits.cc\/alliance\/wp-json\/wp\/v2\/comments?post=133"}],"version-history":[{"count":0,"href":"https:\/\/mybenefits.cc\/alliance\/wp-json\/wp\/v2\/pages\/133\/revisions"}],"wp:attachment":[{"href":"https:\/\/mybenefits.cc\/alliance\/wp-json\/wp\/v2\/media?parent=133"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
Anthem Pharmacy Reimbursement Claim Form<\/a>
Anthem Mail Order Pharmacy Reimbursement Claim Form<\/a><\/p>\n
Click here to be re-directed to the Vision Benefits page.<\/a><\/p>\n
Day Care FSA Receipt for Services<\/a>
Recurring Day Care Claim Form<\/a>
Direct Deposit Request Form<\/a><\/p>\n
Roth IRA Payroll Deduction Authorization Form<\/a><\/p>\n
<\/a><\/p>\n
\n**Please note that all reimbursements are considered as taxable.<\/p>\n
\nPTO Sell Back Request Form<\/a>
\nFriends Helping Friends PTO Donation Form<\/a>
\nPublic Service Loan Forgiveness Employment Service Form<\/a>
\nWellness Activity Liability Acknowledgement Form<\/a>[\/et_pb_tab][\/et_pb_tabs][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"