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Forms & Documents

Forms & Documentssite-admin2020-10-15T20:07:35+00:00

  • Benefit Plan Summaries and SBCs

  • Employer Forms

  • Employee Forms

  • Benefit Plan Summaries and SBCs

  • Plan 1 – Classic 500 Deductible Plan | SBC
  • Plan 2 – Classic 1000 Deductible Plan | SBC
  • Plan 3 – Classic 2000 Deductible Plan | SBC
  • Plan 4 – Classic 3500 Deductible Plan | SBC
  • Plan 5 – Classic 5000 Deductible Plan | SBC
  • Plan 6 – HSA 5000 Deductible Plan | SBC
  • Plan 7 – HSA 6650 Deductible Plan | SBC
  • Plan 8 – Value 7350 Deductible Plan | SBC
  • Plan 9 – ACO 0 Deductible Plan | SBC
  • Plan 10 – ACO 5000 Deductible Plan | SBC
  • Overview Summary
  • Prescription Benefit Plan Summary

  • Employer Forms

  • Health Benefits Plan Census Form
  • Employer Certification Form
  • Health Plan Participation Request/Contract
  • Automated Clearing House (ACH) Form
  • Group Employer Questionnaire
  • Participant Enrollment/Change Form
  • TDCBT Annual Notices

  • Employee Forms

  • Personal Health Questionnaire (PHQ) Form
  • Health Benefit Waiver Form
  • TDCBT Annual Notices
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