Publications, Notices and Forms

Many Federal and State regulations apply to our benefit plans. In accordance with those regulations specific documents and notices are required to be available to you.

Plan Documents

OneBeacon Health & Welfare Summay Plan Description - 2011

OneBeacon 401(k) Savings and Employee Stock Ownership Plan Summary Plan Description - 2011

Pension Summary Plan Description

Deferred Compensation Plan Section 10(a) Prospectus

Summary Annual Report - 2010

Pension Plan Schedule SB - 2009

Pension Annual Funding Notice - 2010

Notices

Health Insurance Portability and Accountability Act (HIPAA) - related link 2009 HIPAA Notice of Privacy Rights

Consolidated Omnibus Reconciliation Act (COBRA)

401(k) and ESOP Notice - 2011

Creditable Coverage Notice for Medicare Part D - 2011

Medicaid and the Children's Health Insurance Program (CHIP)

Reminder to Female Health Plan Participants

Forms

Dental Claim Form - BCBSMA

Medical Claim Form - BCBSMA

Prescription Reimbursement Claim Form - CVS/Caremark

Pharmacy Mail Order Form - CVS/Caremark

Health Care Spending Account Reimbursement Form - ADP

Affidavit of Domestic Partnership

Adoption Assistance Form

Leave of Absence Request Form (FMLA, Military, Disability)

Weight Loss Benefit Form - This is for Choice PLUS+ subscribers only

Fitness Benefit Form - This is for Choice PLUS+ subscribers only

Health Insurance Disclosure Responsibility Form (HIRD form) - MA Residents only