Active Health & Welfare – Plan Documents & Forms

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View Archived Plan Documents and Notices

Plan Documents & Amendments

Plan A SPD
Plan B SPD
Plan C SPD

Enrollment

Plan A Enrollment Guide
Plan A Enrollment Form
Plan B Enrollment Guide
Plan B Enrollment Form
Plan C Enrollment Guide
Plan C Enrollment Form
Plan K20 Enrollment Guide
Plan K500 Enrollment Guide
Plan K1000 Enrollment Guide
Plan K Enrollment Form

Summary of Benefits & Coverage

Active HW – Plan A
Plan A – Anthem SBC
Plan A & Plan K20 SBC

Active HW – Plan B
Plan B – Anthem SBC
Plan B & Plan K500 SBC

Active HW – Plan C
Plan C – Anthem SBC
Plan C & K1000 SBC

General Forms

2023 Physical Exam Certification Form
Disability Claim Form

General Notices

Summary of Material Modifications & Plan Notices

October 2023 – Mental Health & Substance Use Disorder Benefits
June 2023 – Medical Benefits Pursuant to the End of the COVID-19 Emergency
March 2023 – Physical Exam Required to Keep Lower Deductible Level for 2024 Calendar Year
January 2022 – Deductible Decrease for Indemnity Plans A, B or C
February 2022 – Clarification regarding Calculating Disability Pay Effective September 1, 2019
Effective January 1, 2022 – Increase to Orthodontic Maximum for Participants & their Dependents (including COBRA Beneficiaries)

Notice of Creditable Coverage

2022 Notice of Creditable Coverage

Summary Annual Report

2022 SAR
2019 SAR
2018 SAR
2016 SAR