Major Medical Plan

• Health Insurance Enrollment Form-HOURLY

• Health Insurance Enrollment Form-SALARY

• Health Insurance Claim Form

• Dental Insurance Claim Form

• Vision Claim Form

• Change/Term Election Application

• Death Claim Form

*Kanawha Web Site Address*
www.khsonline.com

*Kanawha Customer Service Number*
1-800-822-1274

Minor Medical Plan

• Health Insurance Enrollment Form

• Medical Claim Form

• Dental  Claim Form

*Aetna/SRC Web Site Address*
www.aetna.com

*Aetna/SRC Customer Service Number*
1-888-772-9682

Prescription Drug Benefit Provider


*Express Scripts Web Site Address*
www.express-scripts.com

*Express Scripts Customer Service Number*
1-866-214-6679

Voluntary Plan

• Enrollment Form
• Rate Tables
• LTD Claim Form
• STD Claim Form
• Death Claim Form
• Evidence of Insurability Form

*Fort Dearborn Web Site Address*
www.fdl-life.com

*Fort Dearborn Customer Service Number*
1-800-348-4512

401(k) Plan

• Enrollment Form
• On-Line Registration Instructions
• Phone Registration Instructions
• Beneficiary Designation Form
• Distribution Request Form
• Hardship Withdrawal Request Form

*Daily Access Web Site Address*
www.dailyaccess.com

*Daily Access Customer Service Number*
1-888-535-4322