Forms

Available here is nearly every claim, enrollment and change form necessary to administer our benefit programs.  Please visit frequently as these forms may change.  If you are not able to locate an appropriate form, please Contact Us. You can also request a supply of selected forms by completing and submitting the online Supply Request form.

These forms are in a PDF format.  You will need the Adobe Acrobat Reader to view any of the documents.  If you do not have the Acrobat Reader, please visit the Adobe website, where you can download the free software.

Claim Forms | Enrollment Forms

Supply Request Form | Customer Feedback Form

Benefit Summary Pages

Need a quick overview of benefits? The benefit summaries are perfect for a glance of coverage levels. Just click to download, view or print as many copies as you need. You will need the Adobe Acrobat Reader to view these files. Contact Us with any questions.

Highmark Blue Shield PPO Benefit Summaries

• PPOBlue® Option I
• PPOBlue® Option II
• PPOBlue® Option III
• PPOBlue® Option IV
• PPOBlue® Option V
• PPOBlue® Incentive Option Rx
• PPOBlue® Open Option Rx
• PPOBlue® 2009 Incentive Formulary Pocket Guide
• PPOBlue® Formulary Rx Search
• Signature 65
• Group 5 Select PPO 2600

Prescription Drug plans are creditable according to the Centers for Medicare and Medicaid Services guidelines. For more information regarding creditable coverage, please download and review the Creditable Coverage Information sheet.

Other Highmark Blue Shield Benefit Summaries

Other Pennsylvania Chamber Insurance Summaries:

• Part time Employee Benefit Program Brochure
• Preventive Care–2010 Covered Services Schedule
• Wellness Discounts
• United Concordia Basic Dental
• United Concordia Premier Dental
• The Dental Network
• Davis Vision Value Vision
• Davis Vision Standard Vision
• Davis Vision Crystal Vision
• NVA Fixed Insured Options
• NVA Opti Vision Plus Plan
• NVA Opti-Vision Plan
• Prescription Drug Creditable Coverage Information
• Guardian Basic Life/AD&D Life Benefit Guide
• Benefits for Existing Businesses (Prior 1.1.05)

Benefit Booklets

Below are links to the benefit booklets for the PA Chamber Insurance programs. Choose the correct plan(s) and download the appropriate booklets. You will need the Adobe Acrobat Reader to view any of the handbooks. You may print as many as needed. Contact Us with any questions.

Other Pennsylvania Chamber Insurance Booklets

• Part-time Employee Benefit Program Brochure
• Dental Basic (UCCI)
• Dental Premier (UCCI)
• Dental Network Protect-A-Dent Premier 2
• Dental Network Protect-A-Dent Premier 4
• Dental Network Protect-A-Dent Select 2
• Dental Network Protect-A-Dent Select 4
• Vision (Davis Vision) Value Vision
• Vision (Davis Vision) Standard Vision
• Vision (Davis Vision) Crystal Vision
• Vision (NVA) Insured Plan
• Vision (NVA) Opti Vision Plus Plan
• Vision (Optichoice)
• Guardian Life
ooooo Plan A (Standard $20,000)
ooooo Plan B (Multiple of Salary)
ooooo Plan C (Flat Amount other than Standard)
ooooo Plan D (Flat Amount other than Occupation
ooooo Guardian Life Plan E (Group5Select Standard
          $15,000)
ooooo Basic Life/AD&D Life Benefit Guide
ooooo Basic Life/AD&D Life Benefit Guide 1.1.05
oooo
• Guardian Life (Disability Coverages)
(Coverage effective 8.1.06)
ooooo Short Term Disability Benefit Guide
ooooo Long Term Disability Benefit Guide
• Guardian Short Term Disability Certificates
ooooo Plan D3
ooooo Plan D4
ooooo Plan D5
ooooo Plan D6
ooooo Plan D7
ooooo Plan D8
ooooo Plan D9
ooooo Plan D10
ooooo Plan D11
ooooo Plan D12
ooooo Plan D13
ooooo Plan D15
• Guardian Long Term Disability Certificates
ooooo Plan D16
ooooo Plan D17
ooooo Plan D19
ooooo Plan D20
ooooo Plan D21
ooooo Plan D22
ooooo Plan D23