Active Employee Benefit Information and Forms

Employees working over 20 hours per week on a regular basis that are entitled to benefits can review those benefits below. Benefits can be changed during open enrollment or when a life change occurs. The SMART Plan - Empower Retirement and Colonial Life can be changed or added at anytime during the year. You do not have to wait for open enrollment for those changes. 

Blue Cross Blue Shield Health Insurance - Part of the Hampshire Group Trust

  1. BCBS Blue Care Elect Preferred PPO Benefits Summary
  2. BCBS Network Blue New England HMO Benefits Summary
  3. Benefits Summaries and Prescription info
  4. CanaRX
  5. CVS Caremark Prescription Summary
  6. Fitness Reimbursement info
  7. Qualifying Event Handout
  8. FY24 Benefit Rates

Altus Dental & Vision

  1. Altus Dental Benefits Summary
  2. Altus Preventive Rewards Flyer
  3. Altus Vision Benefit Summary

Colonial Life Insurance

  1. Colonial Life Benefits
  2. Colonial Life - Interest Form

Smart Plan- 457B

  1. SMART Plan Rep
  2. Multiple Beneficiaries Designation Form 98966-01
  3. Direct Rollover form
  4. Beneficiary Designation Form
  5. Enrollment form 98966-01 Voluntary
  6. SMART How Much Can I Contribute
  7. SMART Plan Overview

UNUM Long Term Disability

  1. Long Term Disability Enrollment Form - TOWN OF CHARLTON
  2. Long Term Disability - Unum Plan Summary - TOWN OF CHARLTON
  3. _Unum EAP Assistance

Boston Mutual Life Insurance

  1. _Boston Mutual Group Benefit Summary
  2. Town of Charlton - Employee GVTL Rate Grid
  3. Town of Charlton - Spouse GVTL Rate Grid
  4. Certificate Change Form Fillable Beneficiary Group
  5. Affidavit of Surviving Children
  6. Voluntary Enrollment form
  7. Enrollment Card

Flexible Spending Account/Dependent Care Account

  1. WEX Health Payment Card_Benny Blue Card Flyer
  2. FSA - 1600 Flyer - Cafeteria Plan Advisors (2)
  3. FSA - EXPENSE LIST-OTC
  4. Dependent Care Claim NEW ADDRESS as of 9.1.22

Worcester Regional Retirement

  1. Group 1 - Hired before 4.2.2012 percentage chart
  2. Group 4 - Hired before 4.2.2012 percentage chart
  3. WRRS Beneficiary change form
  4. Windfall Elimination Provision
  5. Moving Out of State
  6. Application for Withdrawal of funds

Employee Assistance Program - EAP

  1. MIIA EAP Services information

Forms 

  1. Employee Direct Deposit
  2. M-4 State Tax
  3. W4 2023 - Federal Tax
  4. Change of Address
  5. FY24 Observed Holidays
  6. FY24 Holiday Schedule - Town Hall
  7. FMLA Poster