Forms/Documents

Health Care
Medical, Dental, Vision	Aetna Dental Claim Form BCBSTX Claim Form BCBS Global Core Program Claim Form (US Domestic) BCBS Global Core Program Claim Form (European) Express Scripts Claim Form Express Scripts Getting Started with Home Delivery Express Scripts Preferred Drug/Exclusion List Express Scripts Preventive Drug List VSP Claim Form
Health Savings Account (HSA)	HSA Transfer Request Form
Spending Accounts
Flexible Spending Accounts Health Care FSA Dependent Care FSA Limited Purpose FSA	Inspira Financial Health Care Limited Purpose Claim Form Inspira Financial Dependent and Health Care Claim Form
Income Protection
Group Universal Life	Group Universal Life Beneficiary Designation Form International: MetLife Beneficiary Designation Form
Disability Short-Term Disability Long-Term Disability	LTD Evidence of Insurability Form
Basic Life - LTD Participant	LTD Beneficiary Designation Form
Unions Basic Life Optional Life Basic AD&D Occupational AD&D Voluntary AD&D	Beneficiary Designation Form
Other
	Acceptable Dependent Documents Domestic Partner Affidavit Form Payroll: Direct Deposit Form Income Tax Withholding Instructions Federal Tax Withholding Calculator Federal Tax Withholding Form (W-4) State Tax Withholding Forms

Health Care
Medical, Dental, Vision	BCBS Global Core Program Brochure BCBS Global Core Program: Locating a Provider Express Scripts Getting Started with Home Delivery Express Scripts Preferred Drug/Exclusion List Express Scripts Preventive Drug List Transparency in Coverage Rule – Machine Readable Files VSP Member Claim Reimbursement Guidelines
Supplemental Health Care Accident Insurance Critical Illness Insurance Hospital Indemnity Insurance	Accident Plan Summary Critical Illness Plan Summary Hospital Indemnity Plan Summary
Spending Accounts
Flexible Spending Accounts Health Care FSA Dependent Care FSA Limited Purpose FSA	Inspira Financial Reimbursement Accounts Claim Filing Guidelines
Income Protection
Accidental Death & Dismemberment (AD&D) Basic AD&D Voluntary AD&D Occupational AD&D (OAD&D)	Basic AD&D Summary Overview Occupational AD&D Summary Overview Zurich AD&D Conversion Process
Disability Short-Term Disability Long-Term Disability	Short-Term Disability Program Guide
Retirement
401(k) Savings Plan & Retirement Plan	Leaving Oxy Guide Investment Fund Fact Sheets
Other
	2024 Employee Benefits Guide Time Away Program Guide

Health Care
New Hire and Open Enrollment Notices	401(k) Savings Plan Automatic Enrollment Notice CHIP Notice Employee Rights Under FMLA HIPAA Privacy Notice New Health Insurance Marketplace Coverage Notice
Medical, Dental, Vision	Summary of Benefits and Coverage Aetna HMO SBC (Wichita 119) Aetna Open Access Managed Choice POS (Wichita 119) Aetna Open Choice QPOS PPO (Wichita 119) BCBSTX HDHP SBC BCBSTX PPO SBC Summary Plan Descriptions Aetna Dental SPD BCBSTX HDHP SPD BCBSTX PPO SPD BCBSWNY Medical SPD Independent Health HMO Medical SPD Prescription Drug SPD UHC SPD (Global Health Insurance Program) Vision SPD 2nd.MD Program
Supplemental Health Care Accident Insurance Critical Illness Insurance Hospital Indemnity Insurance	Accident Insurance High Plan Cert. Accident Insurance Low Plan Cert. Accident Insurance Regulatory Disclosure Accident Insurance Outline of Coverage Disclosure Critical Illness Insurance Plan Cert. Critical Illness Insurance Regulatory Disclosure Critical Illness Insurance Outline of Coverage Disclosure Hospital Indemnity Insurance High Plan Cert. Hospital Indemnity Insurance Low Plan Cert. Hospital Indemnity Insurance Regulatory Disclosure Hospital Indemnity Insurance Outline of Coverage Disclosure Hospital Indemnity Insurance Tri-Agency Disclosure
Spending Accounts
Flexible Spending Accounts Health Care FSA Dependent Care FSA Limited Purpose FSA	Summary Plan Descriptions FSA SPD Limited Purpose FSA SPD
OxyHealth
EAP	Summary Plan Descriptions Lyra Employee Assistance Program
Income Protection
Basic Life	Summary Plan Descriptions Basic Life Insurance SPD Group Universal SPD
Accidental Death & Dismemberment (AD&D) Basic AD&D Voluntary AD&D Occupational AD&D (OAD&D)	Summary Plan Descriptions Basic AD&D SPD Voluntary AD&D SPD Occupational AD&D SPD
Group Universal Life	Summary Plan Descriptions Group Universal Life SPD
Disability Short-Term Disability (STD) Long-Term Disability (LTD)	Short-Term Disability Program Guide Summary Plan Descriptions Long-Term Disability SPD
Retirement
401(k) Savings Plan	401(k) Fee Disclosure 401(k) – Oxy Stock Fund Prospectus Limits and Contributions Notice of Proposed Exemptions Oxy EACA and QDIA Notices Safe Harbor Special Tax Notice and Fee Disclosure Summary Plan Descriptions 401(k) Savings Plan SPD
Retirement Plan	Retirement Plan Fee Disclosure Summary Plan Descriptions Retirement Plan SPD
Other
	Colorado FAMLI Program Notice OCC: Medicare Notice of Creditable Coverage OCC: Medicare Notice of Non-Creditable Coverage OPC: Medicare Notice of Creditable Coverage Required Federal Notices: Actives, no Grandfather Rights and Protections Against Surprise Medical Bills – Federal Disclosure USERRA Notice HIPAA Special Enrollment Notice COBRA Cotinuation of Coverage Notice WHCRA Notice Summary of Benefits and Coverage Notice and Severance Pay Plan Benefits Summary Summary Plan Descriptions Cafeteria Plan SPD Wellthy Employee Assistance Program Midland Health Clinic SPD Notice and Severance Pay Plan SPD Change in Control Severance Plan SPD Incentive Compensation Program Variable Compensation Program Summary Annual Reports 001 OPC Savings SAR 060 OPC Retirement SAR 591 OPC Welfare SAR

Health Care