PO Box 1095 Kirksville, MO 63501 cva@charitonvalley.org Phone: 660-665-1111 Fax: 660-665-1409

Continuation of Coverage, no changes

If you wish to be automatically enrolled in the new Anthem comparable plan as you were last year, please complete the continuation/no changes form below, and also either your HSA or FSA participation form, return to the office no later than Friday June 19 by 5pm.

Continuation of Coverage, No Changes, Declining Form (If declining all benefits, please check the appropriate box)

FSA Participation Form (If you selected one of the 1500/2500 Copay PPO Health Plan)

HSA Participation Form (Hourly Employees 24 pay periods) If you selected the 2500 High Deducible Health Plan

HSA Participation Form (Admin Exempt Employees 12 pay periods) If you selected the 2500 High Deducible Health Plan

Please return these forms to Curtis Mason in HR via email at cmason@charitonvalley.org, or fax to 660-665-1409, or in person at the Business Office. These forms must be completed and returned by June 19th by 5pm.

Accessibility
Click to listen highlighted text!