Documents, Forms, and Required Notices
Documents
Health Plans
Medical Plans
2025
- Health Plan Comparison
- Benefits at a Glance
- Summary of Benefits and Coverage
- Benefits at a Glance
- Summary of Benefits and Coverage
- Benefits at a Glance
- Summary of Benefits and Coverage
- Benefits at a Glance
- Summary of Benefits and Coverage
Dental Plan
Vision Plan
Life Insurance Plans
- UNUM Basic Life Certificate of Coverage (1x Pay)
- UNUM Basic Life Certificate of Coverage (1.5x Pay)
- UNUM Basic Life Certificate of Coverage (2x Pay)
- UNUM Optional Life Insurance Certificate of Coverage
Disability Plans
Retirement Plans
Forms
Health Plans
- BCBSM Member Reimbursement Claim Form
- BCBSM Prescription Drug Reimbursement Claim Form
- BCN Member Reimbursement Claim Form
- Delta Dental Out of Network Claim Form
- VSP Out of Network Claim Form
Legally Domiciled Adult
- Legally Domiciled Adult Certification Form. Use when adding and LDA, send to MCC Benefits.
- Legally Domiciled Adult Tax Treatment Certification Form. Use when adding an LDA and provide to employer for tax purposes.
- Legally Domiciled Adult Decertification Form. Use when removing an LDA because they no longer meet the LDA eligibility requirements.
Flexible Spending Accounts
- Health Care FSA Reimbursement Form
- Dependent Care FSA Reimbursement Form
- Orthodontia Reimbursement Form
- Annual Salary Reduction Agreement
Life Insurance Plans
- Beneficiary Designation Form—Group Life, Accidental Death & Dismemberment
- Group Life and/or Accidental Death Claim Form
- Instructions for Online UNUM Evidence of Insurability Form
- Online UNUM Evidence of Insurability Form
- Life and AD&D Insurance Election of Portability Coverage
- Optional Life Insurance Election of Portability Coverage
Disability Plans
- Short Term Disability Application
- Short Term Disability Authorization Agreement Electronic Funds Transfer
- Form W-4 (Federal Tax Withholding Form)
- Form MI-W4 (Michigan Tax Withholding Form)
- Short Term Disability Continuing Disability Statement
- LTD Claim Form
Retirement Plans
Lay Employees’ Retirement Plan (LERP)
- LERP Beneficiary Designation Form for Plan Death Benefit
- Request for Pension Estimate
- Request for Retirement Application Kit
- Direct Deposit Form
- Federal Tax Withholding Form
- Michigan Tax Withholding Form
Michigan Catholic Conference 403(b) Retirement Savings Plan
Please log-in to you Empower account or contact Empower at 877-778-2100 to make deferral elections and changes, investment elections and update beneficiary designations.
Required Notices
- Children’s Health Insurance Program (CHIP) Notice
- HIPPA Privacy Policy and Procedures for Protected Health Information
- Newborn’s and Mother’s Health Protection Act Notice
- Special Enrollment Rights Notice
- Women’s Health and Cancer Rights Act Enrollment Notice
- Your Rights and Protections Against Surprise Medical Bills
- Notice of Creditable Prescription Drug Coverage
How to Submit Forms to MCC
Please read How to Submit Forms to MCC.