Employee Benefit Enrollment Application Form - Department Of Insurance & Risk Management - 2016

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DEPARTMENT OF INSURANCE & RISK MANAGEMENT
2016 EMPLOYEE BENEFIT
COUNTY OF SUMMIT
175 S. MAIN STREET, ROOM #103
ENROLLMENT APPLICATION
AKRON, OHIO 44308
330.643.2621
FAX: 330.643.8625
EMPLOYEE
DATE OF BIRTH
LAST NAME
FIRST NAME
MIDDLE INITIAL
HOME ADDRESS
ZIP CODE
STREET
CITY/TOWN
STATE
SEX
EMPLOYEE S.S.#
MARITAL STATUS
HOME #
WORK #
SINGLE
MARRIED
F
M
WIDOWED
DIVORCED
COUNTY AGENCY
IS YOUR SPOUSE ALSO EMPLOYED BY THE
DATE OF HIRE
COUNTY OF SUMMIT?
YES
NO
*PREMIUMS WILL BE REDUCED BY COMPLETING THE VITALITY HEALTH REVIEW
MEDICAL
SINGLE
FAMILY
WAIVE BENEFIT
CIRCLE ONE:
MEDICAL MUTUAL PPO ADVANTAGE*
$26.08
$70.23
CASH OPTION
PRE-TAX
MEDICAL MUTUAL PPO PLUS*
$28.26
$76.04
POST-TAX
MEDICAL MUTUAL MV PLAN
$17.11
$46.09
DENTAL
CIRCLE ONE:
SINGLE
FAMILY
WAIVE BENEFIT
GUARDIAN PPO
$0.00
$0.00
OPT-OUT
GUARDIAN VALUE PLAN
$0.00
$0.00
GUARDIAN DHMO
$0.00
$0.00
DHMO PROVIDER #: ________________
VISION
SINGLE
FAMILY
WAIVE BENEFIT
CIRCLE ONE:
DAVIS VISION
$0.00
$0.00
OPT-OUT
YOU MAY CONTRIBUTE UP TO $2,550.00 ANNUALLY.
HEALTH CARE FLEXIBLE SPENDING ACCOUNT
HEALTH CARE ACCOUNT ELECTION $________ PER YEAR
YOU MAY CONTRIBUTE UP TO $5,000.00
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
ANNUALLY PER HOUSEHOLD.
DEPENDENT CARE ACCOUNT ELECTION $________ PER YEAR
PLEASE LIST ADDITIONAL DEPENDENTS ON SEPARATE SHEET AND ATTACH TO THIS FORM. NEW DEPENDENTS MUST INCLUDE BIRTH/MARRIAGE CERTIFICATE. IF ADDING
ELIGIBLE DEPENDENTS
A DEPENDENT AGE 26 OR 27, PLEASE COMPLETE THE ADULT DEPENDENT ELIGIBILITY QUESTIONNAIRE (AVAILABLE IN DEPT OF LAW, INSURANCE & RISK MANAGEMENT).
LAST NAME
FIRST NAME, M I
SOCIAL SECURITY #
RELATIONSHIP
DATE OF BIRTH
SEX
(SPOUSE/CHILD/STEP-
(MONTH/DAY/YEAR)
CHILD/SPONS. DEP.)
F
SELF
M
F
M
F
M
F
M
F
M
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