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.
COMPLETE PRIME (MAC)
BLUE VIEW VISION OPTION 59
_________ _________ _________ _________
Employee/Spouse _________ Employee/Child(ren) _________
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.
2016 Page 13
Made with FlippingBook