Forms & Documents

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Forms (Participants)

100 Benefit Plan Enrollment Application Packet (LTD & Life/AD&D Insurance)

Benefit Plan Enrollment Application Packet for Long Term Disability & Life/AD&D Insurance - for coverage starting January 2020 or after. Contains all forms for enrollment (101, Limitations & Exclusions, 102, 103, 138).
Filename: 100 - Benefit Enrollment Application FILLABLE - 11152019.pdf
Size: 662 KB
Forms (Participants)

100 2023 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) for coverage starting January 1, 2023 or later. Packet includes 101, Limitations & Exclusions, 102, 103, and 138.
Filename: 100-Benefit Plan Enrollment Application Packet FILLABLE - 2023.pdf
Size: 1105 KB
Forms (Participants)

102 Benefit Plan Beneficiary Designation Form for Life/AD&D Insurance

Form to UPDATE beneficiary information for Life/AD&D Insurance.
Filename: 102 - Beneficiary Designation FILLABLE - 09132019.pdf
Size: 418 KB
Forms (Participants)

102 2023 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 - 2023.pdf
Size: 397 KB
Forms (Participants)

103 Benefit Plan Salary Worksheet for LTD

Form to UPDATE salary information for LTD insurance
Filename: 103 - Salary Worksheet FILLABLE - 11152019.pdf
Size: 244 KB
Forms (Participants)

103 2023 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 - 2023.pdf
Size: 266 KB
Forms (Churches/Employers)

104 2023 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 - 2023.pdf
Size: 294 KB
Forms (Churches/Employers), Information

120 Benefit Plan Employer Agreement for LTD & Life/AD&D Insurance

Benefit Plan (LTD & Life/AD&D insurance) adoption agreement for employer.
Filename: 120 - Employer Benefit Agreement FILLABLE - 11152019.pdf
Size: 327 KB
Forms (Churches/Employers), Information

120 2023 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 - 2023.pdf
Size: 383 KB
Forms (Churches/Employers), Information

121 2023 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 - 2023.pdf
Size: 1186 KB
Forms

135 Benefit Plan - How to File a Long Term Disability Claim

Steps to follow when filing a claim for Long Term Disability benefit.
Filename: 135 How to File a Long Term Disability Claim 2101.pdf
Size: 160 KB
Forms, Information

138 Benefit Plan Coverage Overview (LTD & Life/AD&D Insurance)

Summary of Benefit Plan Coverage for Long Term Disability and Life/AD&D Insurance
Filename: 138 - Coverage Overview 1909.pdf
Size: 214 KB
Forms (Participants), Information

138 2023 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 - 2023.pdf
Size: 250 KB
Forms (Participants), Information

150 2023 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 - 2023.pdf
Size: 1501 KB
Information

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

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, Information, Brochures

FCMM Benefit Plan Brochure (effective Jan 2023)

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

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