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Documents and Forms

Benefits

Domestic Partner Affidavit

Domestic Partnership Termination Affidavit

Qualifying Life Events

Unum – How to File a Claim

Plan Documents

Rivian 401(k) Plan SPD	401(k) Plan SMM – December 2024
Rivian Welfare Benefit Plan SPD	401(k) Plan SMM – April 2025
Rivian Flexible Benefits Plan SPD	Rivian Welfare Benefit Plan SMM 2024
Qualified Disaster Relief Payments Plan	Rivian Welfare Benefit Plan SMM – Progyny
Rivian 401(k) Plan Summary Annual Report 2024	Rivian Welfare Benefits Plan Summary Annual Report 2024

Medical—Anthem

2025	2026
Anthem PPO 1000 Summary of Benefits and Coverage	Anthem PPO 1000 Summary of Benefits and Coverage
Anthem HRA 3500 Sumary of Benefits and Coverage	Anthem HRA 3500 Sumary of Benefits and Coverage
Anthem HSA 1650 Summary of Benefits and Coverage	Anthem HSA 1700 Summary of Benefits and Coverage
Anthem HSA 6350 Summary of Benefits and Coverage – Intern	Anthem HSA 6350 Summary of Benefits and Coverage – Intern
Anthem PPO 1000 Summary Plan Description
Anthem HRA 3500 Summary Plan Description
Anthem HSA 1650 Summary Plan Description
Anthem HSA 6350 Summary Plan Description

Medical—Kaiser Permanente

2025	2026
RIV 2025 Kaiser Norcal SBC	RIV 2026 Kaiser Norcal SBC
RIV 2025 Kaiser Norcal DHMO Chiro Benefit Summary	RIV 2026 Kaiser Norcal DHMO Chiro Benefit Summary
RIV 2025 Kaiser Norcal DHMO Benefit Summary	RIV 2026 Kaiser Norcal DHMO Benefit Summary
RIV 2025 Kaiser Socal SBC	RIV 2026 Kaiser Socal SBC
RIV 2025 Kaiser Socal DHMO Chiro Benefit Summary	RIV 2026 Kaiser Socal DHMO Chiro Benefit Summary
RIV 2025 Kaiser Socal DHMO Benefit Summary	RIV 2026 Kaiser Socal DHMO Benefit Summary

Dental

RIV 2025 Delta Dental PPO Benefit Summary

Delta Dental Plan Summary

Vision

RIV 2025 Eyemed Benefit Summary	VSP Enhanced Featured Frame Allowance
RIV 2026 VSP Benefit Summary	VSP Eyeconic Overview
EyeMed Summary of Benefits	VSP Online
	VSP Out-of-Network Benefits
	VSP Summary of Benefits

Health Savings Account

HealthEquity HSA Transfer Request Form

Life and AD&D Insurance

Securian Basic Life & AD&D Coverage	Securian Supplemental/Voluntary Life Cost & Coverage
Securian Employee Group Term Life Certificate of Insurance	Securian Group Accidental Death and Dismemberment Insurance Policy
Securian Group Term Life Insurance Policy and Amendment #1	Securian Group Accidental Death and Dismemberment Insurance Policy Certificate

Additional Medical Benefits

Progyny Member Guide	Intro to Curaechoice (English & Spanish)
Progyny HRA SBC (Kaiser)	Rivian Adoption & Surrogacy Assistance Program

Required Notices

Children’s Health Insurance Program (CHIP)	Rivian HIPAA Data Privacy Notice
COBRA Coverage	Special Enrollment
Family and Medical Leave Act (FMLA)	Transparency in Coverage Machine-Readable Forms
Genetic Information Nondiscrimination Act (GINA)	Uniformed Services Employment and Reemployment Rights Act (USERRA) Coverage
Medicare Part D Creditable Coverage	Women’s Health and Cancer Rights Act (WHCRA)
Michelle’s Law	No Surprises Act Notice
Newborns’ and Mothers’ Health Protection Act	Unum Colorado FAMLI Program Notice – English
Patient Protection and Affordable Care Act Health Coverage Reminder	Unum Colorado FAMLI Program Notice – Espanol