Five College Consortium

For Five College Staff

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Summaries and Description
FY17 Benefits Summary
Health and Dental Care Information 2017
Certificate of Insurance
Summary of Benefits - PPO
Summary of Benefits - HMO
HIPAA Privacy Notice Updated for September 23 2013
Affordable Care Act - Health Insurance Marketplace Coverage Options
Harvard Pilgrim HMO Pediatric Dental Benefit

Delta Dental PPO Subscriber's Certificate

Election Form Health FSA March 17 2016
Health Reimbursement (HRA) Welcome Letter
Health Reimbursement (HRA) Summary Plan Description (SPD)
Health Reimbursement (HRA) Summary (SBC)

Election Form Health FSA March 17 2016
Flexible Spending Summary (FSA) Plan Description (SPD) (Effective 1/1/2014)
Flexible Spending Summary (FSA) Amended & Restated Plan Document (Effective 1/1/2014)
FSA/HRA HIPAA Privacy Notice 09-23-2013

403B Retirement Plan Summary Plan Description 7/1/2014 (SPD)
403B Retirement Plan Summary Annual Report 2015 (SAR)

Emeriti Plan Highlights
Emeriti Summary Plan Description (SPD)
Emeriti Summary Annual Report 2015 (SAR)
Summary of Material Modifications

Five Colleges Group Monthly Disability Plan updated April 2013
Five Colleges Group Life Insurance Plan
FCI Workers' Comp Policy June 2013


Agreement for Salary Reduction under Section 403(b)
HRA Claim Form
Employee Tuition Waiver Request Form
Affidavit of Domestic Partnership Form
Transportation Subsidy Enrollment Form


Employee Application for Medical Leave
Medical Leave Physician Statement
Medical Leave Return to Work Physician Statement
Statement in Support of Need for Domestic Violence Leave