All completed forms should be sent to:
Attn: Nate Kortokrax
199 S. Central Avenue
Columbus, OH 43223
Summaries of Benefits and Coverage (SBC), Benefit Summaries, Certificates of Coverage and Uniform Glossary of Terms
- H.S.A. Plan
- PPO 1 Plan
- PPO 2 Plan
Anthem Benefits Booklet – Overview of Anthem’s programs, services, resources and “Benefit Summaries”.
- Uniform Glossary of Terms – This is not specific to either of the three plans but is very helpful for understanding various terms and how your plan works
- Annual Benefit Notices – For all new hires and during open enrollment
Netcare is contracting wih an outside vendor to handle the administration and notification of your rights under COBRA and ability to continue the insurance if a qualifying event occurs. While Netcare is aware of events such as terminations of employment, it is YOUR responsibility to notify Nate Kortokrax of any qualifying events so they can
Anthem Enrollment Application – ALL new employees are required to complete this form even if you are waiving coverage. (The same application is used for medical, dental and vision.)
Anthem’s network providers are responsible for submitting any claim forms to Anthem on your behalf. However, if you have services provided by a non-network provider, you will need to pay that provider directly and complete the claim forms below for any reimbursements.
Anthem Website: www.anthem.com
Hours: 8:30am to 6:00pm, EST
Certificates of Coverage – Detailed descriptions of your benefit coverage, limitations
Netcare is contracting with an outside vendor to handle the administration and notification of your rights under COBRA and ability to continue the insurance if a qualifying event occurs. While Netcare is aware of events such as terminations of employment, it is YOUR responsibility to notify Nate Kortokrax of any qualifying events so they can
Non-Network Dental Claim Form – Complete and mail this form along with a copy of your bill to Delta Dental if your dentist isn’t willing to do it for you.
Delta Dental Website: www.deltadentaloh.com
Customer Service Phone: 800-524-0149
Online Provider Lookup – Be sure to select either the “Delta Dental PPO” or “Delta Dental Premier” network.
How To – Instructions on how to create your account on Delta Dental online, print your ID card and find a dentist.
Reference ID cards – Delta Dental does not provide personalized ID cards but these can be printed and given to your dentist when you visit them.
Other helpful information and flyers:
- Apple and Android app information for your smart phone
- Easy Reference Card to Delta’s telephonic service inquiry system
- How benefits coordinate with other dental insurance
- How Delta Dental pays for orthodontic services
Evidence of Coverage – Detailed information about your vision benefits including appeals, exclusions, etc.
Netcare is contracting with an outside vendor to handle the administration and notification of your rights under COBRA and ability to continue the insurance if a qualifying event occurs. While Netcare is aware of events such as terminations of employment, it is YOUR responsibility to notify Nate Kortokrax of any qualifying events so they can in turn notify the Insurance Company.
Employee Application and Beneficiary Form: For newly eligible employees, or for any employees to update beneficiary information.
Conversion and Portability – When you leave Netcare you can convert (Conversion Application) the group or supplemental term life insurance to an individual whole life plan. You can also “Port” (Portability Application) your supplemental term life insurance. This allows you to maintain the coverage as a term life benefit which is typically less expensive but increases in cost over time.
Other Forms and Information:
Evidence of Insurability – For late enrollees or those electing coverage amounts in excess of the Guarantee Issue levels.
Free Will Prep Service
Beneficiary Election and Change Form
Life Accident Claim Form
Accelerated Death Benefit Form
Waiver of Premium Claim Form
- Short-Term Disability Claim Form – Human Resources must complete Section 2 before you can send the completed form to Mutual of Omaha.
- Long-Term Disability Claim Form – Human Resources must complete Section 2 before you can send the completed form to Mutual of Omaha.
- Accelerated Death Benefit Form – Allows you to take a portion of your life insurance before your death under certain circumstances.
- Waiver of Premium Claim Form – In the event you have a total disability, this is the form you need to complete and submit. If approved, Mutual of Omaha will then pay your premiums until your Social Security Normal Retirement Age (SSNRA).
- Life Claim Form – Human Resources must complete Section 1 and then the beneficiary/claimant will complete the remaining portion of the form and submit it to Mutual of Omaha.
Employee Assistance Program (EAP) – The unlimited telephonic and six face to face visits (including Travel Assistance) are available for all benefit eligible employees (those working 20+ hours per week) and their dependents. For those working less than 20 hours, only the telephonic services are available.
In the event of a death, please the notify Human Resources office immediately so the appropriate claim forms and other paperwork can be forwarded to the appropriate individual(s) for completion.
Phone: (740) 815-8440
Note: Rates included in this document increased on 1/1/17 and are subject to future increases.
521 Village Park Drive
PO Box 2038
Powell, OH 43065
Local Phone: 614-431-9540
Milestone Benefits Agency: www.milestonebenefits.com
Contact information signs – Content information about this website and how to contact your representatives at Milestone Benefits Agency, Inc.
Disclaimer: The information contained on this site serves as a resource for the employees and administrators of your employer and in some instances only contains an overview of the benefits, provisions, limitations and exclusions of these programs. Information can sometimes change and may not be current on this site. In all instances, if the information contained on this site conflicts with the applicable plan documents or carrier administration of these programs, the plan documents and their administrative policies will prevail. Each company reserves the right to change these benefits at any time without prior notice and at their own discretion.
PO Box 2038
Powell, Ohio 43065
Hours of Operation: