Benefit Enrollment Form - Archdiocese Of Louisville
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1$9.36
$22.92
$20.42
$35.64
__
ARCHDIOCESE OF LOUISVILLE
BENEFIT ENROLLMENT FORM - 2016 PLAN YEAR
PARISH, SCHOOL, AGENCY:__________________________________________________
Subgroup #:
___________
EMPLOYEE INFORMATION (please print clearly)
Name:_______________________________________________________________________________ SSN__________________________
Last
First
Middle
Home Phone:_______________________________________
Work Phone:_______________________________________
Home Address:_________________________________________________________________________________________________
Street
City
State
Zip
Date of Birth: ______________________
Sex:______________
Marital Status:________________
Original Hire Date: _________________
Job Title:_________________________________________________
Local Hire Date: ___________________
Hours Worked (per week):___________
Weeks Worked (per year):__________
Annual Salary: $_________________
Employees must work 30 or more hours per week to be eligible for benefits.
BENEFITS PROVIDED BY THE ARCHDIOCESE OF LOUISVILLE
TERM LIFE INSURANCE
Beneficiary's Name:________________________________________________________________
Relationship:_____________________
Last
First
Middle
LONG TERM DISABILITY COVERAGE
BENEFITS PAID FROM EMPLOYEE PRE-TAX INCOME
MEDICAL COVERAGE (Check one)
Coverage First
Individual
$487.64
Employee +1
$975.28
Family
$1,462.88
If I have elected to cover my spouse under my medical coverage, I hereby advise that my spouse is not eligible for coverage
under his/her employer. By signing this form below, I certify this information to be true and correct to the best of my knowledge
and understand that any misstatement constitutes fraud.
I do not elect medical coverage.
DENTAL COVERAGE (Check one)
Preventive Plus
Humana PPO
Traditional Preferred
EE
$14.34
EE
$25.96
EE
$34.80
EE+SP
$31.26
EE+SP
$45.88
EE+SP
$69.12
EE+CH
$35.06
EE+CH
$50.92
EE+CH
$70.48
Family
$54.56
Family
$87.22
Family
$114.34
I do not elect dental coverage.
FLEXIBLE SPENDING ACCOUNTS - Indicate amount to be contributed in whole dollars.
Any monies remaining in spending accounts at plan year end will be forfeited in accordance with IRS regulations.
Health Care Account $_____________ per month (minimum $75 per month; maximum $2,550 per year)
Dependent Care Acct $____________ per month (minimum $75 per month; maximum-see plan booklet)
I do not elect to participate in the Flexible Spending Accounts.
BENEFITS PAID FROM EMPLOYEE TAXABLE INCOME
SHORT-TERM DISABILITY (see plan booklet for rates)
I do not elect Short-term Disability
I have received the 2016 Summary Plan Description and understand that I cannot change my benefit elections, except for specific reasons
permitted by the IRS, until the next open enrollment.
EMPLOYEE SIGNATURE:_____________________________________________________
DATE:_____________________
BOOKKEEPER/ADMINISTRATOR:______________________________________________
DATE:_____________________
NOTE: Original For Parish Files; Pink To Employee; Yellow To Chancery.
Benefit Enrollment Form 2016.xls
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