Flexible Benefit Election Form

ADVERTISEMENT

NAME _____________________________________
BRYN MAWR COLLEGE
FLEXIBLE BENEFIT ELECTION FORM
ID NUMBER ________________
PLAN YEAR NOVEMBER 2015 TO OCTOBER 2016
EFFECTIVE DATE _________________________
EMPLOYEE: COMPLETE SECTIONS 1-5. Please see rate sheet for all monthly costs.
SECTION 1:
MEDICAL PLAN
(Select one plan and one coverage level.)
PERSONAL CHOICE PPO
SINGLE
PERSONAL CHOICE PPO HIGH DEDUCTIBLE
SINGLE W/DOMESTIC PARTNER
KEYSTONE POS
PARENT & CHILD(REN)
KEYSTONE HMO
EMPLOYEE & SPOUSE
FAMILY
WAIVE (SEE SECTION 4)
FAMILY W/DOMESTIC PARTNER
SECTION 2:
DENTAL (
Single coverage is an employer-paid benefit. Select a coverage level only if enrolling dependents.)
SINGLE
SINGLE W/DOMESTIC PARTNER
X
PARENT & CHILD
PARENT & CHILDREN
EMPLOYEE & SPOUSE
FAMILY
FAMILY W/DOMESTIC PARTNER
(Select “Waive” if receiving only the employer-paid basic benefit of $25,000.)
SECTION 3:
SUPPLEMENTAL LIFE INSURANCE
COVERAGE AMOUNT
EMPLOYEE
birthdate ___/___/___
____________________
SPOUSE/DOM. PARTNER birthdate ___/___/___
____________________
CHILD(REN)
____________________
WAIVE
NO CHANGES
SECTION 4:
MEDICAL INSURANCE WAIVER
I
,
N ORDER TO WAIVE MEDICAL COVERAGE
CERTIFICATION OF GROUP MEDICAL INSURANCE COVERAGE IN FORCE ELSEWHERE FOR THE
. P
. P
P
.
EMPLOYEE IS REQUIRED
LEASE COMPLETE THE INSURANCE INFORMATION BELOW
LEASE
RINT
Name of Insurance Company
Policy /Group #
Policyholder/Employer
ID #
SECTION 5:
SUMMARY
I wish to become insured for the coverage chosen as evidenced by my signature below and agree to the following:
1. I authorize the above selections and, any pre-tax and/or after-tax reductions in pay, as specified on the rate sheet.
2. I understand that insurance applications are requested for each plan in which I enroll and must be submitted by the
due date to ensure enrollment.
3. I understand that if I waive medical coverage, the subsidy that I receive is fully taxable.
4. I understand that I cannot change or revoke these elections unless that change or revocation is on account of and
consistent with a life event change in status.
SIGNATURE
DATE
Life Event Change Date ___________________
Marriage
Divorce
Birth/Adoption
Loss of other group coverage
Enrollment in other group coverage
Other _____________________
EMPLOYEE:
PLEASE KEEP A COPY FOR YOUR RECORDS

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Wells Fargo - Flexible Benefits Plan Election Form / Salary Reduction Agreement Wells Fargo - Flexible Benefits Plan Election Form / Salary Reduction Agreement Business
Form Ers Gi-1.180 - Benefits Election Form - Employees Retirement System Of Texas Form Ers Gi-1.180 - Benefits Election Form - Employees Retirement System Of Texas Medical
Form 2809 - Health Benefits Election Form Form 2809 - Health Benefits Election Form Medical
Standard Form 2809 - Health Benefits Election Form Standard Form 2809 - Health Benefits Election Form Medical
Standard Form 2809 - Health Benefits Election Form Standard Form 2809 - Health Benefits Election Form Legal
Retiree Benefit Election Form Under 65 Retiree Benefit Election Form Under 65 Legal
New Retiree Health Benefits Election Form - Pleasant Valley School New Retiree Health Benefits Election Form - Pleasant Valley School Medical
Hospice Medicare Benefit Election Form - Health First Hospice Medicare Benefit Election Form - Health First Medical
Middle Georgia State University Benefits Election Form Middle Georgia State University Benefits Election Form Medical
North Dakota Public Employees Retirement System Benefit Election Form North Dakota Public Employees Retirement System Benefit Election Form Business

Related Categories

Parent category: Medical
Download
Go