Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 20
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29B. Employer’s Least Expensive Plan or Avenue H Default Plan
Questions below refer to the employer’s least expensive plan or the Avenue H Default Plan.
Yes
No
1. Does the employee have to enroll in order to add their dependent(s)?
2. When will/did coverage begin? (mm/dd/yy) ___________________
3. When does the company’s next open enrollment begin? (mm/dd/yy)
______________________________________________________
D34314000242029
4. Complete the chart below. Do not include the cost of dental, vision or
other coverage if it is separate.
Monthly Premium
Yearly Health Plan Deductible
Employee’s Portion
Company’s Portion
Individual amount
$
Employee
$
$
Family amount
$
Employee + spouse
$
Employee + child
$
Family
$
C. Employee’s Health Plan Choice
Questions below refer to the plan that the employee has selected. Questions 3-7 refer to “in-network” benefits.
1. Insurance company and plan name: _____________________________________________
2. Policy number, if known: ______________________________________________________
3. Is the deductible $2,500 or less per individual?
Yes
No
4. Is the lifetime maximum benefit $1,000,000 or more?
Yes
No
5. Does the plan pay at least 70% of an inpatient stay (after the deductible)?
Yes
No
6. What benefits are covered under this plan? (Check all that apply.)
Physician visits
Hospital inpatient services
Pharmacy/Rx
7. Does the plan cover abortion services? If yes, under what circumstances:
Yes
No
Only in the case where the life of the mother would be endangered if the fetus were carried to
term or in the case of incest or rape.
Other, please describe: ____________________________________________________
8. Complete this chart only if it is different from the chart in section B.
Do not include the cost of dental, vision or other coverage if it is separate.
Monthly Premium
Yearly Health Plan Deductible
Employee’s Portion
Company’s Portion
Individual amount
$
Employee
$
$
Family amount
$
Employee + spouse
$
Employee + child
$
Family
$
9. Are the employee’s children currently enrolled or do they plan to enroll in your company’s dental
Yes
No
plan? If yes, name(s): ____________________________________________________
D. Signature
I certify that I am a representative of the Human Resource Department, or that I am the health insurance contact person.
The information on this form is true and correct to the best of my knowledge.
Signature:
Date:
Name (please print):
Title:
Phone:
Please return completed form to:
Department of Workforce Services, PO Box 143245, SLC, UT 84114-3245
Fax: 1-801-526-9500
Toll-free Fax: 1-877-313-4717
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162
Page 20
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