Benefits Forms

401a Allocation

RETIREMENT FORM - "401a Allocation of Retirement Plan Contributions". Set the allocation of contributions between TIAA-CREF and/or Fidelity. Updated for 7/1/2017 eligibility changes.

PDF document icon 27-401aAllocationForm_2020_Revised.pdf — PDF document, 95 KB (97320 bytes)

401a SPD

RETIREMENT DOCUMENT - "AUI Retirement Plan Summary Plan Description". Eligibility, enrollment, access, payments and general information.

PDF document icon 401aSPD.pdf — PDF document, 80 KB (82826 bytes)

403b SPD

RETIREMENT DOCUMENT - "Summary Plan Description: AUI Supplemental Retirement Annuity Plan - AUI/NRAO TDA Plan". General information, eligibility, deposits and withdrawals, and investing.

PDF document icon SPD for the AUI 403_b_ Plan - November 2011.pdf — PDF document, 44 KB (45257 bytes)

403b SRA

RETIREMENT FORM - "Agreement for Salary Reduction". Set the amount and schedule to be deducted from employee's salary for TIAA-CREF and Fidelity retirement fund contributions.

PDF document icon 403bEnroll.pdf — PDF document, 182 KB (186492 bytes)

AD&D SPD

AD&D DOCUMENT - "Group Accident Insurance Certificate". General information, schedule of benefits, eligibility, and claims.

PDF document icon AD&D-SPD-OK965412P.pdf — PDF document, 143 KB (147043 bytes)

AFLAC Enrollment

PDF document icon AFLACEnrollment.pdf — PDF document, 248 KB (254419 bytes)

Benefit Eligibility Matrix

PDF document icon BenefitEligibilityMatrix_Final2023 (003).pdf — PDF document, 99 KB (102327 bytes)

Benefits Summary - Current Year

BENEFITS DOCUMENT - "Current Year Benefit Program Summary". Overview of all benefits and premiums.

PDF document icon 2022BenefitSummary_Revised.pdf — PDF document, 406 KB (416630 bytes)

CHIP Notice

MEDICAL DOCUMENT - "Children's Health Insurance Program/Medicaid Notice". Contact information for premium assistance through state programs.

PDF document icon CHIPNotice-updateannually.pdf — PDF document, 80 KB (82576 bytes)

Cigna Assurance

LIFE-LTD ARTICLE - "The CignaAssurance Program for Beneficiaries". Overview of counseling, legal and financial services for Life and LTD beneficiaries.

PDF document icon CIGNAssurance.pdf — PDF document, 355 KB (364028 bytes)

Cigna ChoiceFund

HSA ARTICLE - "Health Savings Account - Cigna Choice Fund". Overview of how the HSA works and it's benefits.

PDF document icon ItsYourChoice_HSA_v4.pdf — PDF document, 391 KB (400592 bytes)

Cigna Outreach

BENEFITS ARTICLE - "Why is Cigna Calling Me?". Explanation of how and why Cigna contacts you by phone.

PDF document icon CIGNAOutreach.pdf — PDF document, 754 KB (773017 bytes)

Cigna UsingMyCigna.com

BENEFITS ARTICLE - "Using MyCigna.com". Overview of what the website provides access to.

PDF document icon Mycigna.pdf — PDF document, 139 KB (143025 bytes)

Dental ClaimForm

DENTAL FORM - "Claim and Predetermination". Use this form to submit claims and for pre-determination of any service exceeding $250.

PDF document icon DeltaDentalClaim.pdf — PDF document, 87 KB (89872 bytes)

Dental LowPlan - SPD

DENTAL DOCUMENT - "Low Plan Summary Plan Description". Summary of what the plan pays.

PDF document icon 5 - AUI NRAO Associated Universities Low Plan 2021.pdf — PDF document, 131 KB (134344 bytes)

Dental LowPlan - EOC

DENTAL DOCUMENT - "Low Plan: Delta Member Handbook and Evidence of Coverage". How to use the plan, eligibility, filing claims and general information.

PDF document icon 70008305#20120914 Low.pdf — PDF document, 275 KB (282351 bytes)

Dental HighPlan - SPD

DENTAL DOCUMENT - "High Plan Summary Plan Description". Summary of what the plan pays.

PDF document icon 6- AUI NRA0 Associated Universities High Plan 2020.pdf — PDF document, 135 KB (138731 bytes)

Dental HighPlan - EOC

DENTAL DOCUMENT - "High Plan: Delta Member Handbook and Evidence of Coverage". How to use the plan, eligibility, filing claims and general information.

PDF document icon 70008304#20120914 High.pdf — PDF document, 295 KB (302658 bytes)

EAP Description

EAP DOCUMENT - "Employee Assistance Program". Program overview.

PDF document icon eapinfo.pdf — PDF document, 12 KB (13143 bytes)

EAP Spring Newsletter

BENEFITS ARTICLE - "Lifelines". Health tips.

PDF document icon EAPSpring 2014.pdf — PDF document, 1.10 MB (1149014 bytes)

EAP Wellness

BENEFITS ARTICLE - "Path to Wellness". Tips to improve wellness.

PDF document icon eap_wellness.pdf — PDF document, 527 KB (539706 bytes)

EAP Stress

BENEFITS ARTICLE - "Stress and Our Perceptions". Identifying and dealing with the sources of stress.

PDF document icon eap_stress.pdf — PDF document, 210 KB (215552 bytes)

EAP HowTo

BENEFITS ARTICLE - "Employee Orientation to the Employee Assistance Program." EAP overview, benefits, and program access.

PDF document icon eap_howto.pdf — PDF document, 195 KB (199684 bytes)

EEAP TuitionReimburse

EEAP FORM - "Employee Education Assistance Plan Tuition Reimbursement Form". Tuition reimbursement form for those already admitted to the program.

PDF document icon EEAPreimburse.pdf — PDF document, 263 KB (270299 bytes)

EEAP Degree App

EEAP FORM - "Employee Education Assistance Degree Program Application". Application to enter the program.

PDF document icon EEAPapp.pdf — PDF document, 265 KB (271437 bytes)

EEAP TuitionFees

EEAP DOCUMENT - "Tuition and Fees at Virginia's State-Supported Colleges and Universities". Report of current year rates.

PDF document icon 2013-2014_VA_tuitionAndFeesReport.pdf — PDF document, 746 KB (764338 bytes)

Fidelity Fund Options

RETIREMENT DOCUMENT - "Fidelity Fund Options". List of available options - updated January 2012.

PDF document icon New 2012 Investment Options.pdf — PDF document, 35 KB (36282 bytes)

FSA PlanDoc

FSA DOCUMENT - "AUI Flexible Spending Accounts Plan". General information, eligibility, accounts, and claims.

PDF document icon fsaplandoc.pdf — PDF document, 1.01 MB (1057833 bytes)

HA CostEstimator

BENEFITS ARTICLE - "Health Advocate Cost Estimator". How to use the Cost Estimator.

PDF document icon healthcostestimatorflyer.pdf — PDF document, 766 KB (784439 bytes)

HA CDHP

BENEFITS ARTICLE - "Get the Most from Your Consumer Driven Health Plan". How the Personal Health Advocate service can maximize your health plan.

PDF document icon HealthAdvocdhp.pdf — PDF document, 828 KB (848862 bytes)

HDHP SPD

MEDICAL DOCUMENT - "High Deductible Health Plan Summary Plan Description". Summary of what the plan pays.

PDF document icon CNO38 HSA.pdf — PDF document, 991 KB (1015093 bytes)

HDHP Rider

MEDICAL DOCUMENT - "Cigna Certificate Rider". Massachusetts Employees Only

PDF document icon MA-HSA-Rider.pdf — PDF document, 163 KB (167447 bytes)

HDHP Payments

MEDICAL ARTICLE - "Payments at the Point of Care". How to ensure you pay the right amount up front.

PDF document icon HDHP_Payments.pdf — PDF document, 191 KB (195838 bytes)

HealthcareMarketplace

MEDICAL DOCUMENT - "New Health Insurance Marketplace Coverage Options and Your Health Coverage". 11/30/13 Notice of the Availability of Individual Market.

PDF document icon Marketplace-Noticeweb.pdf — PDF document, 110 KB (113294 bytes)

HRA Summary Plan Description

PDF document icon Associated Univ HRA BenSum 2016.pdf — PDF document, 202 KB (207127 bytes)

HSA Card

HSA ARTICLE - "Using Your HSA Card". Health Savings Account card use at providers, pharmacies, and more.

PDF document icon HSA_card.pdf — PDF document, 387 KB (396653 bytes)

HSA EligibleList

HSA DOCUMENT - "Eligible and Ineligible Expenses". IRS-approved expenses for HRA, HSA, and FSAs.

PDF document icon EligibleHSAExpenses.pdf — PDF document, 198 KB (202992 bytes)

HSA Enroll

HSA FORM - "Agreement for Salary Reduction for Health Savings Account". Complete this form to set a schedule for deductions from your salary for deposit to the HSA.

PDF document icon HSA-2019.pdf — PDF document, 87 KB (89508 bytes)

HSA FAQ

HSA/High Deductible Health Plan FAQs re: HSA plan offering

PDF document icon HSAFAQ.pdf — PDF document, 130 KB (133267 bytes)

HSA Fees

HSA DOCUMENT - "Schedule of HSA Fees". ATM, replacement card, account closing, etc. fees.

PDF document icon HSAFees.pdf — PDF document, 66 KB (68046 bytes)

HSA Investing

HSA ARTICLE - "HSA Investment Service". How to get started investing funds in your HSA account through JP Morgan Chase.

PDF document icon HSAInvesting.pdf — PDF document, 193 KB (198442 bytes)

Healthy Rewards

BENEFITS DOCUMENT - "Programs and Services to Enhance Your Health and Wellness". List of Cigna programs and services to enhance your health and wellness.

PDF document icon HealthyRwds.pdf — PDF document, 75 KB (77433 bytes)

HIPAA Privacy

AUI HIPAA Privacy Notice

PDF document icon PrivacyNotice-11x17.pdf — PDF document, 369 KB (378064 bytes)

Life Application - Dependent

PDF document icon 13- DependentLifeEnrollmentform_Revised.pdf — PDF document, 358 KB (366609 bytes)

Life Insurance Summary Booklet

PDF document icon LifeInsuranceSummary.pdf — PDF document, 255 KB (261696 bytes)

Life SPD

Group Life Insurance Certificate

PDF document icon Life-SPD-FLX963782P.pdf — PDF document, 97 KB (100280 bytes)

Life-LTD Enroll

PDF document icon 2019 LTD.pdf — PDF document, 64 KB (66278 bytes)

LTD SPD

Group Disability Insurance Certificate

PDF document icon LTD-SPDLK962685C01.pdf — PDF document, 93 KB (95334 bytes)

LTD U30 SPD

Group Disability Insurance Certificate - Under 30

PDF document icon LTD-SPD-U30-LK962685C.pdf — PDF document, 93 KB (95761 bytes)

LTD O65 SPD

Group Disability Insurance Certificate

PDF document icon LTD-SPD-O65-LK962685C.pdf — PDF document, 92 KB (95038 bytes)

MD Live Presentation

PDF document icon MDLIVE Customer Enrollment Presentation with video links (2).pdf — PDF document, 276 KB (282779 bytes)

Med-den-vis-enroll-form

Medical, dental and vision enrollment

PDF document icon 11- MedDenVis_Revised.pdf — PDF document, 381 KB (390589 bytes)

Medical Notice

PDF document icon Modified-2014Notice.pdf — PDF document, 1.16 MB (1213894 bytes)

Medical PlanDoc

AUI Comprehensive Medical Insurance Plan

PDF document icon 2014AUIComprehensive Medical Insurance-Signed.pdf — PDF document, 344 KB (353009 bytes)

Medical PremiumComps

Monthly and Bimonthly premium comparison sheets

PDF document icon 2014Premiumscomparison.pdf — PDF document, 193 KB (197946 bytes)

Medicare DNotice

PDF document icon CredibleCoverageNotice_2020.pdf — PDF document, 36 KB (37359 bytes)

OE Notice

PDF document icon PY2016Notice.pdf — PDF document, 2.16 MB (2263128 bytes)

OE FAQ

PDF document icon GeneralFAQ.pdf — PDF document, 75 KB (77711 bytes)

OE Presentation Q&A

PDF document icon OE2015presentationQA.pdf — PDF document, 359 KB (368285 bytes)

OE Presentation Slides

PDF document icon OEPlanYear2017Presentation.pdf — PDF document, 668 KB (684475 bytes)

Preventive Services

PDF document icon PreventiveCoverage1.pdf — PDF document, 223 KB (228582 bytes)

QDIA Factsheet

PDF document icon QDIA_Factsheet_2013.pdf — PDF document, 52 KB (53890 bytes)

QDIA Notice

Qualifying Default Investment Annuity Notice

PDF document icon QDIA-AUIannual notice.pdf — PDF document, 310 KB (317614 bytes)

Retiree MedPresentation

PDF document icon Retireemedpresent.pdf — PDF document, 1.52 MB (1598407 bytes)

Retiree MedAnnounce

PDF document icon RetireeMedicalAnnouncement.pdf — PDF document, 88 KB (90364 bytes)

Retiree MedEligability Graphic

PDF document icon Eligibilitygraphic.pdf — PDF document, 80 KB (82866 bytes)

Retiree MedRedesign FAQ

PDF document icon RetireeMedFAQ.pdf — PDF document, 235 KB (241111 bytes)

RX ClaimForm

Prescription Drug Claim Form

PDF document icon PerscriptionDrugClaim.pdf — PDF document, 707 KB (724613 bytes)

RX Pre-auth

Cigna HealthCare Medication Prior Authorization Form

PDF document icon RX-PreAuth.pdf — PDF document, 23 KB (24144 bytes)

RX Preventive

PDF document icon PrevDrugList_v2.pdf — PDF document, 1.15 MB (1203967 bytes)

RX StepTherapy

PDF document icon StepTherapy Handout.pdf — PDF document, 706 KB (723655 bytes)

Scholarship FAQ

PDF document icon AUI 2017-18 FAQ.pdf — PDF document, 425 KB (436104 bytes)

Scholarship PastWinners

PDF document icon webdoc.pdf — PDF document, 214 KB (220041 bytes)

SecureTravel

Cigna Secure Travel

PDF document icon SecureTravel.pdf — PDF document, 547 KB (560805 bytes)

SMM-Windsor

Summary of Material Modifications to the AUI Employee Welfare Benefit Plan

PDF document icon 16012224_1_SMM Employee Welfare Benefit Plan Same Sex Spouse.pdf — PDF document, 13 KB (13770 bytes)

Summary Annual Report

Summary Annual Report for AUI Retirement Plan

PDF document icon YE2017SAR.pdf — PDF document, 129 KB (132615 bytes)

Tuition PlanDoc

AUI/NRAO Employee Education Assistance Plan

PDF document icon EEAPlandoc.pdf — PDF document, 79 KB (81147 bytes)

Vision Access

Using www.myuhcvision.com

PDF document icon VisionAccess.pdf — PDF document, 621 KB (636134 bytes)

Will Prep

Cigna's Will Preparation Program

PDF document icon 859684_Will_Preparation_flyer_v3.pdf — PDF document, 673 KB (689382 bytes)

Wrap PlanDoc

AUI Employee Welfare Benefit Plan

PDF document icon Wrapplandoc.pdf — PDF document, 1.43 MB (1495292 bytes)

YourHealthFirst

PDF document icon YHFflyer.pdf — PDF document, 631 KB (646505 bytes)

HolidaySchedule

PDF document icon 2015 NRAO Holiday Schedule.pdf — PDF document, 57 KB (58708 bytes)

MD Live Presentation

PDF document icon MDLIVE Customer Enrollment Presentation with video links (2).pdf — PDF document, 706 KB (723673 bytes)

Critical Illness

PDF document icon AFLAC-CriticalIllnessRateSheet.pdf — PDF document, 248 KB (253964 bytes)

Accident Insurance

PDF document icon AC-ratesheet-high.pdf — PDF document, 388 KB (397947 bytes)

Critical Illness Summary

PDF document icon NRAO CI FINAL 10-27-15.pdf — PDF document, 569 KB (582864 bytes)

Accident Insurance Summary

PDF document icon NRAO Acc FINAL 10-27-15.pdf — PDF document, 691 KB (708242 bytes)

Benefit Logon Info

PDF document icon BenefitLogons.pdf — PDF document, 492 KB (504661 bytes)

Commuter Enrollment

PDF document icon CommuterEnrollmentForm.pdf — PDF document, 372 KB (381205 bytes)

Commuter Claim Form

PDF document icon ClaimForm.pdf — PDF document, 546 KB (559263 bytes)

Summary of Coverage and Benefits - HSA

PDF document icon 2017HSA-SBC.pdf — PDF document, 202 KB (207388 bytes)

MedicarePreviousEmpForm

PDF document icon SSAFormfor previousemployment.pdf — PDF document, 105 KB (108177 bytes)

RothEnroll

PDF document icon Roth403b2018.pdf — PDF document, 372 KB (381543 bytes)

2019 Benefit Summary

PDF document icon 2019BenefitSummary.pdf — PDF document, 948 KB (971468 bytes)

Anthem Medical Claim Form

PDF document icon English_Common_Member_Claim.pdf — PDF document, 51 KB (52240 bytes)

Anthem Vision Claim Form

PDF document icon Anthem Vision Claim Form.pdf — PDF document, 41 KB (42409 bytes)

Anthem Mail Order

PDF document icon Mail Order 27832VAMENBVA.PDF — PDF document, 1.37 MB (1440758 bytes)

Web Tour of Anthem Portal

PDF document icon AUI -Web Guided Tour.pdf — PDF document, 115 KB (118420 bytes)

Actwise Member Portal Guide

PDF document icon Act Wise Member Portal Guide VA.PDF — PDF document, 444 KB (454755 bytes)

Anthem Vision Summary

PDF document icon AnthemVisionSummary-ModifiedOON.pdf — PDF document, 166 KB (170982 bytes)

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