Central Valley Craft Beer Employee Election

EMPLOYEE PAYROLL DEDUCTION FORM

_______________________________ Employee Name

UHC Core Bronze PPO 6300

UHC Core Silver 2250

UHC Select Plus Silver 2250

☐ Employee Only

☐ Employee Only

☐ Employee Only

☐ Employee + SP/DP ☐ Employee + Children ☐ Employee + Family ☐ Decline Coverage

☐ Employee + SP/DP ☐ Employee + Children ☐ Employee + Family

☐ Employee + SP/DP ☐ Employee + Children ☐ Employee + Family

MEDICAL

(Monthly Employee Contributions)

Dental: Principal

Vision: Principal (Vision Service Plan)

☐ $23.91 Employee Only ☐ $50.45 Employee + SP/DP ☐ $58.82 Employee + Children ☐ $89.56 Employee + Family

☐ $7.46 Employee Only ☐ $15.92 Employee + SP/DP ☐ $15.89 Employee + Children ☐ $26.05 Employee + Family

VISION

DENTAL

☐ Waive Coverage

☐ Waive Coverage

(Employer Paid) Principal All Eligible Employee’s must enroll. Be sure to complete the Beneficiary designation section.

Group Life /AD&D

Acknowledgement Statement: I understand and agree to the following statements: •

I hereby apply for the coverages I have indicated above on behalf of all dependents and myself, and I authorize my employer to make the appropriate deductions, if any, from my wages to pay for my share of the cost. I understand that the coverages available to me are in accordance with the provisions of the contract between the insurance company and my Group Plan. • I am acknowledging receipt of the Important Documents annual notification Signature of Employee _______________________________________ Date _______________

February 2018 - January 2019

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