Plan Documents & Forms

• Blue Plan Benefit Summary
• Blue Plan SBC
• Blue Plan SPD
• Maize Plan Benefit Summary
• Maize Plan SBC
• Maize Plan SPD
• AmeriHealth Mobile App
• SmithRx Pharmacy Benefits FAQ for Members

2025 Carleton College Health & Welfare Comprehensive Benefit “Wrap” Plan SPD

• BCBS Claim Form
• SmithRx Check Prescription coverage: Pareto Low Global Formulary Look Up Tool
• Notice of a COBRA Qualifying Event

Employee Assistance Program (EAP)

• Value Plan Benefit Summary
• Value Plan SPD
• Comprehensive Plan Benefit Summary
• Comprehensive Plan SPD
• Delta Dental Claim Form

• VSP Member Reference Card
• VSP Choice Member Benefit Summary
• VSP Choice SPD

Mid-Year Contribution Changes for Health Savings Account (HSA) – Done in Workday

Workday Guide (HSA Contribution Changes)

• TIAA Volume Submitter (Wrapped DC and SRA Plan) Document
• TIAA Defined Contribution (403b) Summary Plan Description (SPD)
• TIAA Supplement Retirement Account (SRA) Contribution Changes (Done in Workday)
  • Change Retirement Contribution Guide (in Workday)
• TIAA Lifetime Maximum Deferral Calculation Authorization
• TIAA Annual Retirement Plan Fee Disclosure Notice
• IUOE Central Pension Fund Website – Union Employees

• Flexible Spending Summary Plan Description
• Flexible Spending Claim for Reimbursement (Optum)

• CLSP (Catastrophic Leave Sharing Program) Description for Non-Exempt, Non-Union Staff
• Personal Leave of Absence Form 

• Basic Life & AD&D Certificate – 3.5 times Annual Salary (Group & Voluntary policy)
• Basic Life & AD&D Certificate – Flat $50,000 (Group & Voluntary policy)

Voluntary Long-Term Disability Certificate

• 2025 Health and Welfare Plan Summary Annual Report (SAR)
• 2023 Defined Contribution Retirement Plan Summary Annual Report (SAR)

• Vacation
• Sick
• Earned Sick and Safe Time
• College Holidays & Winter Break
• Floating Holidays 

ACM Business Travel Accident Insurance Plan and Summary Plan Document (SPD) 

Qualifying Events