2017 Benefit Guide

2 / 48

Benefit Election Form
EMPLOYEE INFORMATION
Name (Last, First, Middle initial) Social Security number Date of Hire
Date of Birth Gender Title
Street address City State Zip Code
INSURANCE ELECTIONS
Humana Medical - select from the following two medical plans (choose one):
rates shown are per pay period
NPOS Simplicity OPT 4 NPOS $2000 70/60 OPT 18
 Employee $0.00  Employee $7.12
 Employee & Spouse $286.96  Employee & Spouse $301.19
 Employee & Children $243.91  Employee & Children $257.08
 Family $530.87  Family $551.16
 Waive Medical
AETNA Dental Humana Vision
 Employee $0.00  Employee $0.00
 Employee & Spouse $17.58  Employee & Spouse $2.83
 Employee & Children $22.89  Employee & Children $2.55
 Family $40.38  Family $5.62
 Waive Dental  Waive Vision
Note: By participating in the pre-tax deduction for your medical, dental and vision coverage, you reduce your weekly federal & state payroll
MetLife Life/AD&D/Dependent Life/Long Term Disability
Employer Paid
DEPENDENT INFORMATION
Medical Dental Vision Relationship DOB Gender
 Elect  Elect  Elect
 Elect  Elect  Elect
 Elect  Elect  Elect
 Elect  Elect  Elect
Employee Signature Date
2017-2018
I certify the above is true and correct. I acknowledge that I have been given Ramah Darom Benefits and Services Summary and have been given the opportunity to enroll in Ramah Darom benefits plans. By not enrolling in certain
benefits at this time, I realize that I will be unable to enroll or make changes again until the next open enrollment unless I have a qualifying event as outlined in the Benefits and Services Summary. I hereby authorize Ramah Darom to
reduce my pay for the benefit plans I have selected above. I understand that my contributions will be deducted on a pre-tax basis.
List those dependents (spouse or dependent child) for whom you are selecting medical, dental and vision coverage.
Name(Last, First)
tax making benefits more affordable. This reduced taxable income is shown annually on your W-2 in Boxes 1&3.
Social Security #
M F
M F
M F
M F
1