Human Resources > Benefits Forms

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.

2018AllocForm401a.pdf — PDF document, 227 kB (232,934 bytes)

401a SPD

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

401aSPD.pdf — PDF document, 80 kB (82,826 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.

SPD for the AUI 403_b_ Plan - November 2011.pdf — PDF document, 44 kB (45,257 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.

403bEnroll.pdf — PDF document, 182 kB (186,492 bytes)

AD&D SPD

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

AD&D-SPD-OK965412P.pdf — PDF document, 143 kB (147,043 bytes)

AFLAC Enrollment

AFLACEnrollment.pdf — PDF document, 248 kB (254,419 bytes)

Benefit Eligibility Matrix

BenefitEligibilityMatrix.pdf — PDF document, 41 kB (42,933 bytes)

Benefits Summary - Current Year

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

2018EmployeeBenefitSummary.pdf — PDF document, 396 kB (405,627 bytes)

CHIP Notice

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

2014CHIPNotice.pdf — PDF document, 120 kB (123,706 bytes)

Cigna Assurance

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

CIGNAssurance.pdf — PDF document, 355 kB (364,028 bytes)

Cigna ChoiceFund

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

ItsYourChoice_HSA_v4.pdf — PDF document, 391 kB (400,592 bytes)

Cigna Outreach

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

CIGNAOutreach.pdf — PDF document, 754 kB (773,017 bytes)

Cigna UsingMyCigna.com

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

Mycigna.pdf — PDF document, 139 kB (143,025 bytes)

Dental ClaimForm

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

DeltaDentalClaim.pdf — PDF document, 87 kB (89,872 bytes)

Dental LowPlan - SPD

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

AUI-NRAO Low Plan 2018.pdf — PDF document, 477 kB (489,111 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.

70008305#20120914 Low.pdf — PDF document, 275 kB (282,351 bytes)

Dental HighPlan - SPD

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

AUI-NRAO High Plan 2018.pdf — PDF document, 488 kB (500,112 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.

70008304#20120914 High.pdf — PDF document, 295 kB (302,658 bytes)

EAP Description

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

eapinfo.pdf — PDF document, 12 kB (13,143 bytes)

EAP Spring Newsletter

BENEFITS ARTICLE - "Lifelines". Health tips.

EAPSpring 2014.pdf — PDF document, 1,122 kB (1,149,014 bytes)

EAP Wellness

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

eap_wellness.pdf — PDF document, 527 kB (539,706 bytes)

EAP Stress

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

eap_stress.pdf — PDF document, 210 kB (215,552 bytes)

EAP HowTo

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

eap_howto.pdf — PDF document, 195 kB (199,684 bytes)

EEAP TuitionReimburse

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

EEAPreimburse.pdf — PDF document, 263 kB (270,299 bytes)

EEAP Degree App

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

EEAPapp.pdf — PDF document, 265 kB (271,437 bytes)

EEAP TuitionFees

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

2013-2014_VA_tuitionAndFeesReport.pdf — PDF document, 746 kB (764,338 bytes)

Fidelity Fund Options

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

New 2012 Investment Options.pdf — PDF document, 35 kB (36,282 bytes)

FSA PlanDoc

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

fsaplandoc.pdf — PDF document, 1,033 kB (1,057,833 bytes)

HA CostEstimator

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

healthcostestimatorflyer.pdf — PDF document, 766 kB (784,439 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.

HealthAdvocdhp.pdf — PDF document, 828 kB (848,862 bytes)

HDHP SPD

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

CNO38 HSA.pdf — PDF document, 991 kB (1,015,093 bytes)

HDHP Rider

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

MA-HSA-Rider.pdf — PDF document, 163 kB (167,447 bytes)

HDHP Payments

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

HDHP_Payments.pdf — PDF document, 191 kB (195,838 bytes)

HealthcareMarketplace

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

Marketplace-Noticeweb.pdf — PDF document, 110 kB (113,294 bytes)

HSA Card

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

HSA_card.pdf — PDF document, 387 kB (396,653 bytes)

HSA EligibleList

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

EligibleHSAExpenses.pdf — PDF document, 198 kB (202,992 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.

HSA-2018.pdf — PDF document, 82 kB (84,625 bytes)

HSA FAQ

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

HSAFAQ.pdf — PDF document, 130 kB (133,267 bytes)

HSA Fees

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

HSAFees.pdf — PDF document, 66 kB (68,046 bytes)

HSA Investing

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

HSAInvesting.pdf — PDF document, 193 kB (198,442 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.

HealthyRwds.pdf — PDF document, 75 kB (77,433 bytes)

HIPAA Privacy

AUI HIPAA Privacy Notice

PrivacyNotice-11x17.pdf — PDF document, 144 kB (148,146 bytes)

Life Application - Dependent

Cigna Form to add dependent's to employee coverage. Employee must fill out NRAO form for their own coverage.

DependentLifeEnrollmentform.pdf — PDF document, 2,743 kB (2,809,572 bytes)

Life Insurance Summary Booklet

LifeInsuranceSummary.pdf — PDF document, 255 kB (261,696 bytes)

Life SPD

Group Life Insurance Certificate

Life-SPD-FLX963782P.pdf — PDF document, 97 kB (100,280 bytes)

Life-LTD Enroll

LifeLTDinsuranceForm.pdf — PDF document, 44 kB (45,306 bytes)

LTD SPD

Group Disability Insurance Certificate

LTD-SPDLK962685C01.pdf — PDF document, 93 kB (95,334 bytes)

LTD U30 SPD

Group Disability Insurance Certificate - Under 30

LTD-SPD-U30-LK962685C.pdf — PDF document, 93 kB (95,761 bytes)

LTD O65 SPD

Group Disability Insurance Certificate

LTD-SPD-O65-LK962685C.pdf — PDF document, 92 kB (95,038 bytes)

Med-den-vis-enroll-form

Medical, dental and vision enrollment

med-den-vis.pdf — PDF document, 291 kB (298,913 bytes)

Medical Notice

Modified-2014Notice.pdf — PDF document, 1,185 kB (1,213,894 bytes)

Medical PlanDoc

AUI Comprehensive Medical Insurance Plan

2014AUIComprehensive Medical Insurance-Signed.pdf — PDF document, 344 kB (353,009 bytes)

Medical PremiumComps

Monthly and Bimonthly premium comparison sheets

2014Premiumscomparison.pdf — PDF document, 193 kB (197,946 bytes)

Medicare DNotice

2016Creditable Cover Notice.pdf — PDF document, 232 kB (238,324 bytes)

OE Notice

PY2016Notice.pdf — PDF document, 2,210 kB (2,263,128 bytes)

OE FAQ

GeneralFAQ.pdf — PDF document, 75 kB (77,711 bytes)

OE Presentation Q&A

OE2015presentationQA.pdf — PDF document, 359 kB (368,285 bytes)

OE Presentation Slides

OEPlanYear2017Presentation.pdf — PDF document, 668 kB (684,475 bytes)

Preventive Services

PreventiveCoverage1.pdf — PDF document, 223 kB (228,582 bytes)

QDIA Factsheet

QDIA Factsheet

QDIA_Factsheet_2013.pdf — PDF document, 52 kB (53,890 bytes)

QDIA Notice

Qualifying Default Investment Annuity Notice

AUI Qualified Default Investment Alternative.pdf — PDF document, 30 kB (31,622 bytes)

Retiree MedPresentation

Retireemedpresent.pdf — PDF document, 1,560 kB (1,598,407 bytes)

Retiree MedAnnounce

RetireeMedicalAnnouncement.pdf — PDF document, 88 kB (90,364 bytes)

Retiree MedEligability Graphic

Eligibilitygraphic.pdf — PDF document, 80 kB (82,866 bytes)

Retiree MedRedesign FAQ

RetireeMedFAQ.pdf — PDF document, 235 kB (241,111 bytes)

RX ClaimForm

Prescription Drug Claim Form

PerscriptionDrugClaim.pdf — PDF document, 707 kB (724,613 bytes)

RX Pre-auth

Cigna HealthCare Medication Prior Authorization Form

RX-PreAuth.pdf — PDF document, 23 kB (24,144 bytes)

RX Preventive

PrevDrugList_v2.pdf — PDF document, 1,175 kB (1,203,967 bytes)

RX StepTherapy

StepTherapy Handout.pdf — PDF document, 706 kB (723,655 bytes)

Scholarship FAQ

AUI 2017-18 FAQ.pdf — PDF document, 425 kB (436,104 bytes)

Scholarship PastWinners

webdoc.pdf — PDF document, 214 kB (220,041 bytes)

SecureTravel

Cigna Secure Travel

SecureTravel.pdf — PDF document, 547 kB (560,805 bytes)

SMM-Windsor

Summary of Material Modifications to the AUI Employee Welfare Benefit Plan

16012224_1_SMM Employee Welfare Benefit Plan Same Sex Spouse.pdf — PDF document, 13 kB (13,770 bytes)

Summary Annual Report

Summary Annual Report for AUI Retirement Plan

YE2016SAR.pdf — PDF document, 87 kB (89,918 bytes)

Tuition PlanDoc

AUI/NRAO Employee Education Assistance Plan

EEAPlandoc.pdf — PDF document, 79 kB (81,147 bytes)

Vision Access

Using www.myuhcvision.com

VisionAccess.pdf — PDF document, 621 kB (636,134 bytes)

Will Prep

Cigna's Will Preparation Program

859684_Will_Preparation_flyer_v3.pdf — PDF document, 673 kB (689,382 bytes)

Wrap PlanDoc

AUI Employee Welfare Benefit Plan

Wrapplandoc.pdf — PDF document, 1,460 kB (1,495,292 bytes)

YourHealthFirst

YHFflyer.pdf — PDF document, 631 kB (646,505 bytes)

HolidaySchedule

2015 NRAO Holiday Schedule.pdf — PDF document, 57 kB (58,708 bytes)

Critical Illness

AFLAC-CriticalIllnessRateSheet.pdf — PDF document, 248 kB (253,964 bytes)

Accident Insurance

AC-ratesheet-high.pdf — PDF document, 388 kB (397,947 bytes)

Critical Illness Summary

NRAO CI FINAL 10-27-15.pdf — PDF document, 569 kB (582,864 bytes)

Accident Insurance Summary

NRAO Acc FINAL 10-27-15.pdf — PDF document, 691 kB (708,242 bytes)

Benefit Logon Info

BenefitLogons.pdf — PDF document, 492 kB (504,661 bytes)

Commuter Enrollment

CommuterEnrollmentForm.pdf — PDF document, 334 kB (342,779 bytes)

Commuter Claim Form

ClaimForm.pdf — PDF document, 290 kB (297,591 bytes)

Summary of Coverage and Benefits - HSA

2017HSA-SBC.pdf — PDF document, 202 kB (207,388 bytes)

MedicarePreviousEmpForm

SSAFormfor previousemployment.pdf — PDF document, 105 kB (108,177 bytes)

RothEnroll

Roth403b2018.pdf — PDF document, 372 kB (381,543 bytes)









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