Ramah Darom - 2016 Benefit Guide

Benefit Election Form

2016-2017

EMPLOYEE INFORMATION

Date of Hire

Name (Last, First, Middle initial) Social Security number

Date of Birth

Gender

Title

Street address

City

State

Zip Code

INSURANCE ELECTIONS

Humana Medical - s elect from the following three medical plans (choose one):

NPOS Simplicity OPT 13

NPOS $2000 70/60 OPT 67

NPOS Simplicity OPT 12

$0.00

$24.70 $339.58 $292.35 $607.23

$30.12 $350.42 $302.38 $622.68

 Employee

 Employee

 Employee

$290.18 $246.66 $536.84

 Employee & Spouse  Employee & Children

 Employee & Spouse  Employee & Children

 Employee & Spouse  Employee & Children

 Family

 Family

 Family

 Waive Medical

AETNA Dental

Humana Vision

$0.00 $3.84 $3.45 $7.62

$0.00

 Employee

 Employee

$16.06 $20.77 $36.88

 Employee & Spouse  Employee & Children

 Employee & Spouse  Employee & Children

 Family

 Family

 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

tax making benefits more affordable. This reduced taxable income is shown annually on your W-2 in Boxes 1&3.

MetLife

Life/AD&D/Dependent Life/Long Term Disability Employer Paid

Please print Beneficiary Form and complete

DEPENDENT INFORMATION

List those dependents (spouse or dependent child) for whom you are selecting medical, dental and vision coverage.

Name(Last, First)

Social Security #

Relationship

Medical

Dental

Vision

DOB

Gender

 Elect

 Elect

 Elect

M F

 Elect

 Elect

 Elect

M F

 Elect

 Elect

 Elect

M F

 Elect

 Elect

 Elect

M F

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.

Employee Signature Date

Made with