Benefit Forms
Personnel Data Form
2013 Medical Insurance Enrollment or Change Form
Cigna Dental Enrollment and Change Form
Waiver of Medical/Dental Coverage
Extension of Benefits (COBRA-like) Instructions and Enrollment Form
Salary Continuation (unemployment) Benefits Information and Application
2012 Termination Packet
2013 Termination Packet
Benefit Plan Information/Customer Service
Welcome to the 2013 DioCal Insurance Program
2013 Benefit Rates
Employee Assistance Plan Brochure (For more information, visit www.cpg.org)
2013 Medical Plan Summary / Comparisons
Kaiser High Option Plan Summary
Empire Bluecross Blueshield PPO 80/60 Plan Summary
Empire Bluecross Blueshield EPO 90 Plan Summary
Value-added benefits for medical plan participants:
— Prescription drugs
— Mental health
— Vision
— Hearing aids
— Travel assistance
— Your Health Advocate
Health plans are administered by the Episcopal Church Medical Trust. For more detailed information, plan services, and customer service, visit the Medical Trust website. The ECMT Client Engagement Center can be reached at 800.480.9967 (8 a.m. to 5:30 p.m. Pacific time)
Cigna Dental Benefits
Indemnity policy #3215364
Customer Service: http://www.cigna.com/ or (800) CIGNA24
Cigna Dental Benefit Summary
Cigna Dental Insurance Coverage Booklet
Cigna Dental Claim Form
Student Verification Form
Child's First Dental Visit
Prudential Disability (Lay employees short & long term disability)
Group Control # 99805
Disability Insurance Claim Information Booklet
Disability (short and long term) Claim Forms
Clergy Disability with Church Pension Fund
Customer Service: www.cpg.org
Long Term Care Insurance provided by UNUM
Cathedral School Employees must get materials from school administration, all other employees please send email to sarahc@diocal.org to request materials.
Life Insurance
(no enrollment form required — coverage automatic to employees working 30 or more hours per week)
Change of Elected Beneficiary Designation form (to be mailed directly to Church Life Insurance)
Summary of Group Life and Supplemental Group Life Insurance
Retiree Benefits with Church Pension Group
Customer Service: www.cpg.org