Enrollment Form

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208400-THG
VSI
LOCATION ____________
Rehire Date
OFFICE USE ONLY
__ __ /__ __ /__ __ __ __
ENROLLMENT FORM
ESC/MEC SO P1M v18.1
A. REQUIRED EMPLOYEE INFORMATION
B. MEDICARE INFORMATION
PRINT USING BLACK or BLUE INK (Must Be Filled Out)
Do you or any of your dependents receive
medicare benefi ts?
Name
Home Phone
Yes
No. If Yes:
Social Security #
Date of Birth
Sex
Medicare Health Insurance Claim Number (HICN)
M F
/
/
Address
Apt. #
Medicare Effective Date
City
Zip
State
Name of Covered Person(s):
1.
2.
C. LIMITED BENEFIT PLAN SELECTION
Payroll Deducted Weekly Rates
You MUST enroll in the Fixed Indemnity Medical Insurance Plan before adding any additional benefi ts in Section C.
Your coverage level for the additional benefi ts in Section C will be identical to your fi xed indemnity medical plan selection.
This plan is underwritten by BCS Insurance Company.
FIXED INDEMNITY
SHORT-TERM
DENTAL
VISION
TERM LIFE
MEDICAL
DISABILITY
1
2
$5.40
$2.42
$0.60
$4.20
$19.98
Employee Only
$40.54
$10.80
$4.92
$0.90
Employee + 1
$54.14
$17.82
$6.56
$1.80
Employee + Family
NO to ALL Benefi ts
Yes
No
Yes
No
Yes
No
Yes
No
This coverage is not available to residents of NH, HI, or PR.
STD is not available to persons who work in CA, HI, NJ, NY, or RI.
1
2
For Term Life / Accidental Loss of Life, Limb & Sight, please write in your benefi ciary information. Accidental Loss of Life, Limb &
Sight is part of the Fixed Indemnity Medical Benefi t.
Name
Relationship
D. REQUIRED DEPENDENT INFORMATION
Name
Social Security #
Date of Birth
Sex
Relationship
/
/
M F
Spouse
Child
Domestic Partner
Name
Social Security #
Date of Birth
Sex
Relationship
/
/
M F
Spouse
Child
Domestic Partner
Name
Social Security #
Date of Birth
Sex
Relationship
/
/
M F
Spouse
Child
Domestic Partner
E. OPTIONAL MEC WELLNESS/PREVENTIVE BENEFIT SELECTION
Monthly Rates
82084000-M-THG
Enrolling in the Optional MEC Wellness/Preventive Benefi t may DISQUALIFY you from receiving a subsidy from the health
insurance exchange. This plan satisfi es the federal healthcare reform Individual Mandate. This is an offer of ACA compliant
coverage and by purchasing this plan, you will not be taxed for failing to purchase insurance required by the Affordable Care Act.
The MEC Wellness/Preventive Benefi t is NOT underwritten by BCS Insurance Company. It is a benefi t offered and provided by your
employer. Rates for the MEC Wellness/Preventive Benefi t are billed monthly.
$60.00 Employee Only
$90.87 Employee + 1
$111.29 Employee + Family
NO to MEC Wellness/Preventive
F. REQUIRED SIGNATURE
YOU MUST SIGN AND DATE EVEN IF YOU DECLINE COVERAGE
I have read the Benefi ts Summary and the Limitations and Exclusions for the Fixed Indemnity Medical Plan. I understand that I have been
offered ACA compliant coverage. I understand that open enrollment is only available for a limited time, and I understand that making no
benefit selection is a declination of coverage.
DATE
__ __ /__ __ /__ __ __ __
SIGNATURE
This is an Essential StaffCARE Enrollment Form.

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