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RETIREMENT
SERS
STRS
Employee Payroll Forms
Please print, complete and send directly to LCS Payroll Dept.
Jodi Miller email:
j_miller@lcsschools.net
Beckie Blake email:
r_blake@lcsschools.net
Direct Deposit Form
ESS Setup Instructions
Ohio State Withholding IT4
Payroll Schedule 2025-2026
SSA-1945 Form
STRS SERS MembershipForm
W-4 2025
FMLA
Please print, complete and send directly to LCS Human Resources Dept.
Anne Brengman email:
a_brengman@lcsschools.net
Teri Craiglow email:
t_craiglow@lcsschools.net
Michelle Williams email:
m_williams@lcsschools.net
FMLA FAMILY ILLNESS
FMLA PERSONAL ILLNESS
FMLA-Notice of Eligibility Rights Responsibilities
American Fidelity
AF PREGNANCY QUICKCLAIMS
AMERICAN FIDELITY ACCIDENT ONLY CLAIM
AMERICAN FIDELITY CANCER CLAIM
AMERICAN FIDELITY CRITICAL ILLNESS CLAIM
AMERICAN FIDELITY DISABILITY CLAIM
AMERICAN FIDELITY HOSPITAL INDEMNITY CLAIM
AMERICAN FIDELITY ROUTINE PREGNANCY CLAIM
American Fidelity website link
Workers Compensation
Please direct any questions directly to
Beckie Blake email:
r_blake@lcsschools.net
BWC Designation Agreement
BWC Instructions
BWC Salary Continuation Agreement
BWC Steps
First Report of Injury Form
Injury Flow Chart - WC
Sedgwick Flyer
Required Notices for Open Enrollment and New Hires
2024 Notice of Privacy Practices (distributed every 3 years)
Exchange Notice
Rights and Protections Against No Surprise Medical Bills
Women's Health & Cancer Rights Act
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Summary Plan Description (SPD)
CAREFACTOR DENTAL PLAN
LCSD "GRANDFATHERED" PLAN
OPTIONAL PPO & BRONZE MVP PLANS
Insurance Benefit Rates
2025-2026 Insurance Rates
Employee Communications
CareFactor Member Portal Instructions
Mobile App Instructions
Vision Summary (VSP) (Voluntary)
VSP Doctor Directory
VSP Voluntary Benefits Summary
BENEFIT ENROLLMENT FORMS
BASIC LIFE INSURANCE ENROLLMENT FORM
LCSD MED/DENT ENROLLMENT FORM
Ohio Deferred Compensation
VSP ENROLLMENT FORM
AUL/One America Life Insurance
http://www.int-hr.com
$50k /$75k
Administration Exempt Basic Life Policy
Beneficiary Form for AUL (Board Paid / Vol. Ins.)
Certified & Classified Basic Life Policy
VTL SUPPL RATES 1.1.25
Employee Forms
Accident Claim Form
Authorization for Release of Information Form
Instructions on how to submit an employee form
Other Insurance Information
Prime Therapeutics
Prime App
Prime Mail Order Form
Prime Prior Auth
Prime Rx Reimbursement
Wellness
1800MD Program
Diabetic Program (E3 Program)
EAP AUL ONE AMERICAN
Employee Assistance Program (TELUS)
Employee Assistance Program (TELUS)(App Flyer)
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Contact Information
Eligibility, Benefits, Claim Status Inquiries, or additional ID cards
:
contact CareFactor at 877-304-0761
http://www.mycarefactor.com/
OR
Miller-Lewis Benefit Consultants (Now known as Acrisure)
(name change only) at 740-654-4055
Email:
jahamilton@acrisure.com
Prime Therapeutics Prescription
1-800-424-5821 or email
https://www.primetherapeutics.com/
Prime Therapeutics
Prescription Drug List (Formulary)
https://prime.adaptiverx.com/
webSearch/index?key=
cnhmbGV4LnBsYW4uUGxhblBkZlR5cG
UtOTQw
ACMS
for specialty pharmacy (assistance with high cost medications):
614-335-9004 OR Email:
Enrollment@myacms.com
Ohio PPO Connect
(PPO):
888-258-7621 OR
http://www.ohioppoconnect.com/
National Access Program
(outside of the Ohio PPO Connect coverage area):
800-687-0500 OR
https://providerlookup.healthsmart.com/
Use Group #: SCOIC
American Fidelity
Ryan Dieter - District Representative
877-518-2337 Office/844-565-2235 Fax
Ryan.Dieter@americanfidelity.com
Central Office
Holly Roofe/ Office Manager/ Benefits
740-687-7359
h_roofe@lcsschools.net
Kendra Smith / Office Manager- Human Resources/ Treasurer's Office
740-687-7315
kendra_smith@lcsschools.net
Featured Resources
Live Well, Work Well Newsletter - August 2025