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	About Your Benefits

		Eligibility
		Medical
		Dental
		Vision
		Disability
		Life Insurance
		Flexible Spending Accounts
		Retirement Savings Plan
		Time Off & Leaves
		Voluntary Benefits & Discounts
		Other Benefits
		Administrative Information
		Glossary of Health Insurance Terms
	What if I...?
	Find out what you need to do if you:
		Join Valassis
		Get Married
		Want to Add a Domestic Partner
		Have A Child
		Leave Valassis
		Experience Other Changes...

FORMS & DOCUMENTS

Download Benefits-Related Forms and Documents

Below is a list of forms and documents associated with your benefits. These forms are in PDF - Adobe Acrobat format. When you select a link to a form, the form will open (with Adobe Acrobat software) in a new window. If you do not have Adobe Acrobat software installed on your system, you may download the software from the Adobe site.

Form Type	Form Name
Retirement Savings Plan	Beneficiary Form Rollover Instructions Rollover Application Rollover Certification Fund Performance
Vacation Plan Form	2012 Purchased and Rollover Vacation Form
Adoption Forms	Adoption Reimbursement Plan Application Adoption Time Off Request Form
Benefits Handbook	Coming Soon
Credit Union	Membership Application
Domestic Partners	Domestic Partnership Declaration Termination of Domestic Partnership
Educational Assistance	Education Assistance Application Education Assistance Reimbursement Form
WageWorks	FSA Health Care Reimbursement Form FSA Dependent Care Reimbursement Form PNC HSA Check Contribution Form
Life Insurance	CIGNA forms Coming Soon!
Medical/Dental	Delta Dental Claim Form-Coming Soon! Medical Claim Form Specialty Pharmacy Order Form CVS Prescription Reimbursement Claim Form Understanding Your BCBS Explanation of Benefits (EOB) Statement Dependent Age 26 Enrollment Form
Other Forms	2012 Form W-4 Employment Eligibility Verification Form: I-9 Car Seat Request Form Car Seat Waiver Marriage Gift Card Request Form College/Military Service Care Package Request Form

Important Legal Information: This site is designed to provide easy-to-understand explanations of the key features of the Valassis benefit plans. These descriptions do not necessarily include all the plan details, which are contained in the official plan documents. In the event of any contradiction between the information in these Summary Plan Descriptions and the official plan documents, the official plan documents will govern in all cases. More information...