Open Enrollment

E-Packet

• Open Enrollment Checklist
• Open Enrollment Letter
• Open Enrollment Benefits Summary
• Summary Plan Description 2014

Individual Forms

Medical/Dental

1. Premera Member Enrollment and Change Application
2. Whitman Benefit Changes Open Enrollment Form
3. Premera Health Premiums for 2014
4. Premera Waiver of Coverage (Cash in Lieu)

FSA

1. FSA Info Sheet
2. FSA Brochure – Start Saving
3. FSA Election Form
4. FSA Electronic Deposit Form
5. mySourceCard Brochure
6. Frequently Asked Questions about mySourcecard
7. The Benefits of mySourceCard — Educational Video
8. Making the most of your Flexible Spending Account with the mySourceCard — Educational Video
9. mySourcecard Enrollment Agreement
10. Over-the-counter (OTC) Dr. Authorization
11. 125 FSA Voucher
12. FSA Qualifying & Non-Qualifying Expenses 2014
13. FSA 125 Brochure Whitman