Documents and Forms

Benefits

Domestic Partner Affidavit
Domestic Partnership Termination Affidavit
Qualifying Life Events
Rivian Flexible Benefits Plan SPD
Rivian Welfare Benefit Plan Summary of Material Modifications 2024
Rivian Welfare Benefits Plan Summary Annual Report 2022
Rivian Welfare Benefits Plan Wrap SPD

401(k) Plan

401(k) Plan SPD

Medical—Blue Shield

2023 Blue Shield HSA 1500 Summary of Benefits
2023 Blue Shield HSA 1500 Summary Plan Description
2023 Blue Shield HSA 3500 Summary of Benefits
2023 Blue Shield HSA 3500 Summary Plan Description
2023 Blue Shield HSA Intern Summary of Benefits
2023 Blue Shield HSA Intern Summary Plan Description
2023 Blue Shield PPO 500 Summary of Benefits
2023 Blue Shield PPO 500 Summary Plan Description
2024 BSC PPO 1000 Summary of Benefits
2024 BSC PPO HSA 1600 Summary of Benefits
2024 BSC PPO HSA 3500 Summary of Benefits
2024 BSC PPO HSA 6350 Intern Summary of Benefits
BSC Gender-Affirmation Surgery Policy

Medical—Kaiser Permanente Northern California

2024 Kaiser 1000 NorCal Disclosure Form Part 1
2024 Kaiser 1000 NorCal Summary of Benefits
Kaiser 1000 NorCal Disclosure Form Part 2
Kaiser NorCal Chiropractic and Acupuncture Benefits HMO 500
Kaiser NorCal HMO 500 Disclosure Form Part 1
Kaiser NorCal HMO 500 Summary of Benefits

Medical—Kaiser Permanente Southern California

2024 Kaiser 1000 SoCal Disclosure Form Part 1
2024 Kaiser 1000 SoCal Summary of Benefits
Kaiser 1000 SoCal Disclosure Form Part 2
Kaiser SoCal Chiropractic and Acupuncture Benefits HMO 500
Kaiser SoCal HMO 500 Disclosure Form Part 1
Kaiser SoCal HMO 500 Summary of Benefits

Dental

Delta Dental Plan Summary

Vision

EyeMed Summary of Benefits
VSP Enhanced Featured Frame Allowance
VSP Eyeconic Overview
VSP Online
VSP Out-of-Network Benefits
VSP Summary of Benefits

Wellness

Headspace Overview
Modern Health FAQ
Sibly Top 20 FAQs
Unum EAP Information

Health Savings Account

HealthEquity HSA Transfer Request Form
Kaiser Permanente HSA Transfer Request Form

Life and AD&D Insurance

Life and AD&D Insurance Portability and Conversion Brochure
Life and AD&D Insurance Portability Election
Supplemental Life and AD&D Insurance
U.S. Employer-Paid Life and AD&D Insurance

Other Benefits

IDShield
LegalShield
Nationwide Avian and Exotic Pet Insurance
Nationwide My Pet Protection
Nationwide Pet Insurance 101

Required Notices

Blue Shield Illinois Consumer Coverage Disclosure
Children’s Health Insurance Program (CHIP)
COBRA Coverage
Family and Medical Leave Act (FMLA)
Genetic Information Nondiscrimination Act (GINA)
Medicare Part D Creditable Coverage
Michelle’s Law
Newborns’ and Mothers’ Health Protection Act
Patient Protection and Affordable Care Act Health Coverage Reminder
Rivian 401(k) Plan Summary Annual Report 2021
Rivian 401(k) Plan Summary Annual Report 2022
Rivian HIPAA Data Privacy Notice
Rivian Welfare Benefits Summary Annual Report 2021
Special Enrollment
Transparency in Coverage Machine-Readable Forms
Uniformed Services Employment and Reemployment Rights Act (USERRA) Coverage
Women’s Health and Cancer Rights Act (WHCRA)