Plan Documents and Legal Notices

Plan Documents

Voya – Accident Insurance Plan Summary
Voya – Accident Insurance Certificate of Coverage
Voya – How To File A Claim
Voya – Accident Insurance Claim Form
Accident Illness New Mexico State Mandate (2020)
Accident Illness State Mandate Forms (2019)

Voya – Critical Illness Insurance Plan Summary
Voya – Critical Illness Insurance Certificate of Coverage
Voya – Critical Illness Insurance Wellness Benefit
Voya – How To File A Claim
Voya – Critical Illness Claim Form
Voya – Critical Illness Attending Physician Statement

Delta Dental – Dental Benefit Summary
Delta Dental – Evidence of Coverage

Magellan – EAP Evidence of Coverage

Lennox – Adoption Reimbursement Program
Lennox – Adoption Reimbursement Form
TaxSaver – 2024 FSA Benefit Summary
TaxSaver – Standard FSA Claim Form
Lennox – FSA Flex Debit Card Information

Sedgwick Short-Term Disability Plan Description – Salaried Employees
Sedgwick Short-Term Disability Plan Description – Hourly Employees

New York Life Long-Term Disability Benefit Summary – Salaried Employees
New York Life Long-Term Disability Plan Description – Salaried Employees

New York Life Long-Term Disability Benefit Summary – Hourly Employees
New York Life Long-Term Disability Plan Description – Hourly Employees

Voya – Life and AD&D Certificate of Coverage
Voya – Life and AD&D Evidence of Insurability (EOI) Form

2024

2024 Green Plan Summary of Benefits and Coverage
2024 Green Medical Plan SPD
2024 Blue Plan Summary of Benefits and Coverage
2024 Blue Medical Plan SPD
Lennox – 2024 Tobacco Use Affidavit
Lennox – 2024 Working Spouse Affidavit

2023

2023 Blue Medical Plan SPD
2023 Green Medical Plan SPD

Lennox – Volunteer Time Off Benefit
Lennox – Well-Being Time Off Benefit

OptumRx – Premium Standard Formulary (as of 1/1/24)
OptumRx – Premium Formulary Exclusion List (as of 1/1/24)

EyeMed – Vision Benefit Summary (English)
EyeMed – Vision Benefit Summary (Spanish)
EyeMed – Diabetic Eye Care Benefit (English)
EyeMed – Diabetic Eye Care Benefit (Spanish)

Legal Notices

2024 Required Notices – All Active Employees
2024 CHIP Notice
2024 Wellness Notice
2024 Medicare Part D – Women’s Health and Cancer Rights
Lennox Marketplace Notice
State of Illinois Essential Health Benefit Listing
Your Rights and Protections Against Surprise Medical Bills
2023 Consolidated Pension Plan Annual Funding Notice
2023 Manufacturing Pension Plan Annual Funding Notice