Forms & Documents

Forms (Participants)

pdf 100 Benefit Plan Enrollment Application Packet

This form is required for newly eligible employees enrolling in either the Standard Plan (LTD & Life/AD&D Insurance) or Plus Plan (STD, LTD, & Life/AD&D Insurance). Packet includes 101, Limitations & Exclusions, 102, 103, and 138.
Filename: 100-Benefit Plan Enrollment Application Packet FILLABLE - 2309.pdf
Size: 1513 KB

pdf 101 Benefit Plan Enrollment Application

Included in the Enrollment Application Packet (Form 100). [Basic enrollment form; original enrollment is incomplete without Forms 102 and 103.]
Filename: 101-Benefit Plan Enrollment Application FILLABLE - 2309.pdf
Size: 350 KB
Forms (Participants)

pdf 102 Benefit Plan Beneficiary Designation

Included in the Enrollment Application Packet (Form 100) and can be used to update beneficiary information, which affects the LTD survivor benefit and Life/AD&D insurance. As required by the insurance carrier, the original, hard copy of this form must be mailed to FCMM.
Filename: 102-Benefit Plan Beneficiary Designation FILLABLE - 2309.pdf
Size: 395 KB

pdf 103 Benefit Plan Salary Worksheet

Included in the Enrollment Application Packet (Form 100) and can be used to update salary information, which affects disability premiums and benefit amount.
Filename: 103-Benefit Plan Salary Worksheet FILLABLE - 2309.pdf
Size: 407 KB
Forms (Churches/Employers)

pdf 104 Benefit Plan Application Addendum for Updates

This form can only be completed during the annual open enrollment period after an employer updates their Employer Benefit Agreement (Form 120). Employees receiving a change to their benefits must complete this form.
Filename: 104-Benefit Plan Application Addendum for Updates FILLABLE - 2309.pdf
Size: 432 KB
Forms (Churches/Employers) , Information

pdf 120 Benefit Plan Employer Agreement

New employers to the Benefit Plan must complete this form upon initially entering the plan. Current employers can only updated benefits and coverage during the annual open enrollment period by completing this form. The form details two benefit plan options, employee eligibility, payment methods, and Life/AD&D coverage amounts.
Filename: 120-Benefit Plan Employer Benefit Agreement FILLABLE - 2309.pdf
Size: 554 KB
Forms (Churches/Employers) , Information

pdf 121 Benefit Plan Employer Guide

Contains helpful resources for whomever is administering the Benefit Plan at an organization. The guide contains information regarding coverage highlights, form descriptions, how to complete the Employer Benefit Agreement, premium amounts, payment method descriptions, paying invoice online, and frequently asked questions.
Filename: 121-Benefit Plan Employer Guide - 2309.pdf
Size: 2107 KB
Forms (Participants) , Forms (Churches/Employers)

pdf 135 Benefit Plan - How to File a Claim

Steps to follow when filing a claim for the Benefit Plan
Filename: 135 - Benefit Plan Filing A Claim - 2309.pdf
Size: 373 KB
Forms (Participants) , Information

pdf 138 Benefit Plan Coverage Overview

Summary of Benefit Plan coverage for Short Term Disability, Long Term Disability, and Life with Accidental Death and Dismemberment Insurance.
Filename: 138-Benefit Plan Coverage Overview - 2309.pdf
Size: 250 KB
Forms (Participants) , Information

pdf 150 Benefit Plan Employee Welcome Packet

Contains helpful resources for newly enrolled employees in the Benefit Plan. The welcome packet contains information regarding coverage highlights, premium rates, and frequently asked questions.
Filename: 150-Benefit Plan Employee Welcome Packet - 2309.pdf
Size: 1182 KB
Information

pdf Sample: Salary Continuation Plan Policy

A Sample Salary Continuation Policy for Self-Funded Short-Term Disability Benefits
Filename: Salary Continuation Policy SAMPLE 2017.pdf
Size: 23 KB
Information

pdf Sample: Salary Continuation Plan Resolution

A sample Salary Continuation Plan Resolution and Employee Notification Letter.
Filename: Salary Continuation Plan SAMPLE resolution & EE notice.pdf
Size: 540 KB
Forms (Participants) , Forms (Churches/Employers) , Information , Brochures

pdf FCMM Benefit Plan Brochure

Benefits | Features | Rates | Payment Methods
Filename: 2022 FCMMBrochure_BenefitPlan (web).pdf
Size: 1506 KB
Forms (Participants) , Information

pdf 33 Privacy Notice

Description of FCMM's policy and practices for collection and security of participant data.
Filename: 33 FCMM Privacy Notice 1805.pdf
Size: 92 KB