ENROLLMENT FOR JANUARY 2015-DECEMBER 2015
Medical Benefits
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE MEDICAL PLAN:
New Enrollment
Employee Only
CareFirst BC/BS EPO
Change in plan
Employee & One Child
CareFirst BC/BS PPO
Addition or removal of dependent
Employee & Spouse
Kaiser IHM*
No, I do not want to enroll in
Employee & Family
UnitedHealthcare EPO
this benefit
End Stage Renal (ESRD)
UnitedHealthcare PPO
Cancel current coverage
(
Complete Medicare Information below)
*Members and/or dependents eligible for Medicare due to age, disability, or End Stage Renal Disease (ESRD) are not eligible to enroll in the
Kaiser medical plan.
If you or a dependent have Medicare, write in name, Medicare number, and effective date of Medicare coverage.
PART A
PART B
PART D
MEDICARE
(Hospital Claims)
(Medical Claims)
(Prescription Drug)
NAMES OF INDIVIDUALS
NUMBER
MEDICARE DUE TO (P):
Effective Date
Effective Date
Effective Date
WITH MEDICARE
(with suffix)
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
Age 65
Disabled
ESRD
Employee
Spouse
Child
Child
NOTE: Vision and Mental Health/Substance Abuse benefits are included if enrolled in a medical plan.
Medical plans do not include Prescription Drug or Dental coverage. Separate selections are required.
Prescription Drug Coverage
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
New enrollment
Employee Only
Addition or removal of dependent
Employee & One Child
Employee & Spouse
No, I do not want to enroll in this benefit
Cancel current coverage
Employee & Family
Dental Coverage
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE DENTAL PLAN:
New enrollment
Employee Only
United Concordia DPPO
Change in plan
Employee & One Child
Delta Dental DHMO
Addition or removal of dependent
Employee & Spouse
For the DHMO Plan: You must select
No, I do not want to enroll in this benefit
Employee & Family
a primary Dentist office once enrolled.
Call plan or see plan website for details.
Cancel current coverage
Accidental Death and Dismemberment Benefits
CHOOSE ONE OPTION:
CHOOSE ONE COVERAGE LEVEL:
CHOOSE ONE BENEFIT AMOUNT:
New enrollment
Employee Only coverage
$100,000
Change of benefit amount
Family coverage
$200,000
Addition or removal of dependent
$300,000
No, I do not want to enroll in this benefit
Cancel current coverage
Life Insurance Plan
EMPLOYEE
OPTIONS-Choose only one
Choose a Coverage Amount in increments of $10,000 up to $300,000:
Yes, I want to enroll as a new enrollee in Life
STOP-If you choose an amount greater than $50,000, you must fill out a Life Insurance
Insurance.
Evidence of Insurability form. The life insurance vendor will contact you about completing
I am currently enrolled in Life Insurance and
this form. Amount over $50,000 will not be effective until we receive approval from our life
making a change.
insurance carrier.
No, I do not want Life Insurance for myself.
Fill in the amount of Benefit
Cancel Life Insurance.
,
$
0
0 0 0
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