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Benefits Enrollment Form







Business Network Members
  1. Adair Lumber
  2. Essentially Coping & Caring
  3. First Priority Cleaning Serv
  4. Facilities Maintenance Speci






Benefits Enrollment Template

Word   PDF  



Benefits Enrollment / Change Form


Enrollment Request

[__] New Hire [__] Newly Eligible [__] Rehire

[__] Beneficiary Update

[__] Qualified Life Event (QLE): Date of Event: ____/____/______

Enroll / Add

Employee:

[__] Change in legal marital status

[__] Loss of eligibility or other coverage

[__] Returns from unpaid leave

[__] Moves into plan service area

Spouse / Domestic Partner:

[__] Change in legal marital status

[__] Loss of eligibility or other coverage

[__] Moves into plan service area

Child(ren):

[__] Birth

[__] Adoption

[__] Foster Care

[__] Legal Guardianship

[__] Loss of Eligibility or Other Coverage

[__] Moves into Plan Service Area

[__] Qualified Medical Child Support Order

Remove

Employee:

[__] Change in legal marital status

[__] Gains other coverage

[__] Begins unpaid leave

[__] Moves from plan service area

[__] Death

Spouse / Domestic Partner:

[__] Change in Legal Marital Status

[__] Gains Other Coverage

[__] Dissolves Domestic Partnership

[__] Moves From Plan Area

[__] Death

Child(ren):

[__] Reaches Age 26

[__] Gains Other Coverage

[__] Dissolves Domestic Partnership

[__] Moves From Plan Service Area

[__] Death

Miscellaneous:

[__] Cancel Dependent Life

[__] Cancel Short Term Disability

[__] Change in Day Care Expense or Provider

[__] Non-payment of Premiums During Leave

[__] Eligible for LTD Benefits

[__] Other / Please Explain ____________________________________

Dependent Information

Last Name: _____________________________________________________

First Name and M.I.: ___________________________________________

[__] Male [__] Female DOB: ____/____/______ Disabled? [__] Yes [__] No

Address if Different From Employee: ____________________________

Relationship: [__] Spouse [__] Child [__] Domestic Partner [__] Domestic Partners Child

SSN: ___________________________________________________________

[__] Add [__] Remove

Select Plan For This Dependent: [__] Medical [__] Vision [__] Dental [__] Dependent Life

Last Name: _____________________________________________________

First Name and M.I.: ___________________________________________

[__] Male [__] Female DOB: ____/____/______ Disabled? [__] Yes [__] No

Address if Different From Employee: ____________________________

Relationship: [__] Spouse [__] Child [__] Domestic Partner [__] Domestic Partners Child

SSN: ___________________________________________________________

[__] Add [__] Remove

Select Plan For This Dependent: [__] Medical [__] Vision [__] Dental [__] Dependent Life

Last Name: _____________________________________________________

First Name and M.I.: ___________________________________________

[__] Male [__] Female DOB: ____/____/______ Disabled? [__] Yes [__] No

Address if Different From Employee: ____________________________

Relationship: [__] Spouse [__] Child [__] Domestic Partner [__] Domestic Partners Child

SSN: ___________________________________________________________

[__] Add [__] Remove

Select Plan For This Dependent: [__] Medical [__] Vision [__] Dental [__] Dependent Life

Health Plans

Medical Plans [__] Enroll [__] Decline / Cancel [__] Change [__] No Change

EPO

Provider Networks [__] Aetna [__] CIGNA [__] United Health Care

Coverage Level [__] Employee[__] Employee+Adult [__] Employee + Child [__]Employee+Family

PPO

Provider Networks [__] Aetna [__] CIGNA [__] United Health Care

Coverage Level [__] Employee[__] Employee+Adult [__] Employee + Child [__]Employee+Family

Aetna HSA Option [__]Employee[__]Employee+Adult [__]Employee + Child [__]Employee+Family

Dental Plans

Delta Dental [__] Employee[__] Employee+1 [__]Employee + Family

Total Dental Administrators [__] Employee[__] Employee+1 [__]Employee + Family

Vision Plans

Avesis Advantage [__] Employee[__] Employee+1 [__]Employee + Family

Print Name: ____________________________________________________

Signature: _____________________________________________________

Employee ID#: __________________________________________________

Email Address: _________________________________________________

Date: ____/____/______

For Assistance, please contact the Office of Human Resources Employee Service Center










Business Network Members
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  2. Hovey Cleaning
  3. Upward Transport LLC
  4. VMR Construction Company






Hiring An Employee

Finding A New Employee
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Sample Interview Questions
Interview Thank You Letter
Intake Form

Applying For A Job
Applicant Flow Chart
Blank Job Application
Job Application Letters
Application Release Form
Sample Resume Format
Job Application Cover Letter

New Hire Documents
Benefits Enrollment Form
Emergency Contact
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Return To Work Agreement
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Financial Conflict of Interest
Employee References
Employee Background Check
Military Statement of Service
Employee Handbook Outline
Temporary Employment Agreement
Return to Work Medical Evaluation Form
Medical Evaluation Return to Work Letter

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Telecommuting Checklist
Telecommuting Agreement






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