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EMPLOYEE BENEFITS
ELECTION FORM
2016 Plan Year
Section A. Employee Information
-
-
Name (Last, First, Middle Initial)
Hire Date
(MM/DD/YYYY)
Birth Date
(MM/DD/YYYY)
Social Security No.
Single Married
Domestic Partner
Primary Phone No.
Marital Status
Employee Email Address
Street Address
City
State
Zip
Note: Employee contributions to medical, dental, vision and flexible, Basic Life and Life AD&D spending coverage are
classified as pre-tax contributions. Annual W-2 taxable income will be reduced by the amount of such contributions.
Section B. Insurance Elections – Employee Monthly Contributions
Humana – Medical - NPOS
Humana – Medical - Simplicity
Employee
Employee + Spouse
Employee + Children
Employee + Family
$ 120.00
$ 370.00
$ 342.00
$ 520.00
Employee
Employee + Spouse
Employee + Children
Employee + Family
$ 90.00
$ 320.00
$ 300.00
$ 440.00
WAIVE MEDICAL
Blue Cross - Supplementary Dental (High Option)
Blue Cross - Supplementary Dental (Low Option)
Employee
Employee + Spouse
Employee + Children
Employee + Family
$ 34.97
$ 72.92
$ 85.63
$ 132.97
Employee
Employee + Spouse
Employee + Children
Employee + Family
$ 20.43
$ 42.47
$ 48.52
$ 75.74
WAIVE DENTAL
Blue Cross - Vision
Employee
Employee + Spouse
Employee + Children
Employee + Family
$ 7.57
$ 13.24
$ 14.38
$ 21.95
Basic Term Life AD&D
Salary Amount
Cigna STD
Cigna LTD
Elect
$__________
Elect
Elect
Waive BTL
Waive STD
(Employer Paid)
WAIVE VISION
Blue Cross Supplementary
Term Life
Employee
Spouse
Child
Employee Amount Requested
Spouse Amount Requested
Child Amount Requested
$__________
$__________
$__________
Waive Employee
Waive Spouse
Waive Child
I understand the above options as presented to me. I understand that the choices I have made will remain in effect until I have a
qualifying event which would allow enrollment for me for thirty (30) days OR until the next annual enrollment. Qualifying events
include, but are not limited to, marriage, divorce, birth, adoption, death and loss or gain of coverage.
Signature
Date