2016 Boyle Brasher Benefit Guide

Boyle Brasher LLC

2016 Annual Enrollment

BOYLE BRASHER LLC 2016 DENTAL AND VOLUNTARY VISION ELECTION FORM

I, ________________________________, elect the following Anthem Dental and/or Vision plans effective March 1, 2016.

______ I DO wish to make changes to my current enrollment elections.

______ I am NOT making any changes to my current enrollment elections.

DENTAL

VOLUNTARY VISION

COMPLETE PRIME (MAC)

BLUE VIEW VISION OPTION 59

Employee

_________ _________ _________ _________

Employee

_________

Employee/Spouse Employee/Child(ren)

Employee/Spouse _________ Employee/Child(ren) _________

Family

Family

_________

Waive Coverage

_________

Waive Coverage

_________

It is important to note that if you waive coverage for yourself and/or dependents during this annual enrollment you will not be able to enroll or make changes until next year unless you experience a qualifying event.

I understand my above election will be in effect from March 1, 2016 through February 28, 2017.

Signature______________________________

Date____________________

2016 Page 13

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