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Protected: Documents & Forms

The following documents are available for you to download, save, print or review.  If you print and fill out a form, you can turn it in to dispatch or fax it to 260.440.2000.

BENEFIT INFORMATION

Benefit Booklet – Explains all company provided benefits and eligibility dates.
Summary Plan Description (SPD) – Explains in detail our entire group medical insurance and dental plans.
   Medical Plan A
   Medical Plan B
   Medical Plan C
First Care Walk-In Clinic Info – Locations and Hours for Walk-In Clinics
Core Benefits Online – Information to login and view important benefit information through Core Benefits
Vision Insurance Plan Description – Explains in detail our entire group vision insurance plan.
Life Insurance and Short-Term Disability Certificate of Coverage – This is the employee certificate showing coverage and plan details.

FORMS

W-4 Federal Tax Form – Fill this form out to change your federal exemptions/payroll withholdings.
WH-4 State Tax Form – Fill this form out to change your state exemptions/payroll withholdings.
Direct Deposit Form – Fill this form out to change your direct deposit accounts or allocation amounts or enroll for a new direct deposit.
Medical & Dental Insurance Form – Fill this form out to change coverage
Spousal Carve-Out Form (Coordination of Benefits Form) – Your spouse or spouse’s employer must fill this form out to enroll a spouse onto our group insurance plan.
Vision Insurance Form – Fill this form out to make changes to your insurance coverage elections. You must have a “qualifying event” to make changes during the year. If you do not have a qualifying event, you must wait until our annual open enrollment period to enroll, decline or change coverage. Open enrollment for Vision is during the month of December.