21 / 24
Health: BlueCross and BlueShield of Georgia
BCBS OPEN ACCESS Point of Service $1,500 Annual Deductible
BCBS OPEN ACCESS Point of Service $500 Annual Deductible
Ƒ
,QGLYLGXDO
SHU SD\ SHULRG
Ƒ
,QGLYLGXDO
SHU SD\ SHULRG
Ƒ
(PSOR\HH 6SRXVH
SHU SD\ SHULRG
Ƒ
(PSOR\HH 6SRXVH
SHU SD\ SHULRG
Ƒ
(PSOR\HH &KLOGUHQ
SHU SD\ SHULRG
Ƒ
(PSOR\HH &KLOGUHQ
SHU SD\ SHULRG
Ƒ
)DPLO\
SHU SD\ SHULRG
Ƒ
(PSOR\HH )DPLO\
SHU SD\ SHULRG
Ƒ I do not want health insurance offered by Juneau Construction Company
Flexible Spending Account: (Plan year January through December)
Ƒ
, FKRRVH WR SDUWLFLSDWH LQ WKH +HDOWK &DUH 6SHQGLQJ $FFRXQW
BBBBBBBBBBBB SHU \HDU
PLQLPXP PD[LPXP
Ƒ
, FKRRVH WR SDUWLFLSDWH LQ WKH 'HSHQGHQW &DUH 6SHQGLQJ $FFRXQW
BBBBBBBBBBBBSHU \HDU
PLQLPXP PD[LPXP
Dental: BlueCross and BlueShield of Georgia
Ƒ
,QGLYLGXDO
SHU SD\ SHULRG
Ƒ
(PSOR\HH 6SRXVH
SHU SD\ SHULRG
Ƒ
(PSOR\HH &KLOGUHQ
SHU SD\ SHULRG
Ƒ
(PSOR\HH )DPLO\
SHU SD\ SHULRG
Ƒ I do not want dental insurance offered by Juneau Construction Company
Life:
Prudential
Ƒ I only want the insurance at no cost to employee ($30,000 Basic Life, Short Term and Long Term Disability)
Additiona Ƒ
, KDYH UHTXHVWHG DGGLWLRQDO OLIH LQVXUDQFH IRU PH LQ WKH DPRXQW RIBBBBBBBBBBBBBBBBBBBBBB
Ƒ
, KDYH UHTXHVWHG DGGLWLRQDO OLIH LQVXUDQFH IRU P\ VSRXVH LQ WKH DPRXQW RIBBBBBBBBBBBBBBBBBBBBBBBB
Ƒ
, KDYH UHTXHVWHG DGGLWLRQDO OLIH LQVXUDQFH IRU P\ FKLOGUHQ LQ WKH DPRXQW RIBBBBBBBBBBBBBBBBBBBBBBB
3OHDVH 1RWH (YLGHQFH RI ,QVXUDELOLW\ ZLOO EH UHTXLUHG IRU QHZO\ HOLJLEOH HPSOR\HHV HOHFWLQJ DPRXQWV RYHU WKH JXDUDQWHH LVVXH DPRXQW RI
IRU HPSOR\HH DQG
IRU VSRXVH DQG ZLOO DOVR EH UHTXLUHG IRU DQ\RQH ZLVKLQJ WR LQFUHDVH OLIH LQVXUDQFH DPRXQWV DQG ODWH HQWUDQWV WKRVH WKDW ZDLYHG FRYHUDJH LQ WKH SDVW EXW DUH HOHFWLQJ QRZ
Vision : EyeMed
Ƒ
,QGLYLGXDO
SHU SD\ SHULRG
Ƒ
(PSOR\HH 6SRXVH
SHU SD\ SHULRG
Ƒ
(PSOR\HH &KLOG UHQ
SHU SD\ SHULRG
Ƒ
(PSOR\HH )DPLO\
SHU SD\ SHULRG
Ƒ I do not want vision insurance offered by Juneau Construction Company
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.
SSN:
Date:
Name:
Employee's Information (Please Print)
Address:
Gender:
Date of Birth:
Date of Hire:
Social Security Number:
Gender:
Juneau Construction Exempt Insurance Election Form - Annual Enrollment
2017-2018 Plan Year
Employee's Signature:
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
Dependent's Information (Please Print)
Name: (Last, First)
Relationship:
Date of Birth: