Lab Waxing Inc

Employee Payroll deductions per pay period. (bi-weekly, deductions occur before tax is removed)

Plan Options Blue Cross PPO Network Employee Only Employee & Children Employee & Spouse Employee & Family
Blue Cross Blue Shield PPO Network 2018 2018 2018 2018
2T2W:Anthem Silver PPO $4000 80/20 MAX Op $6850 Office Co-pay $40 Specialist $60 RX: $15/45/85 Specialty Med 30% Max $350/$250 $121.80 $311.79 $321.79 $511.78
2T31:Anthem Health Keepers Silver OAPOS Network $4000 80/20 MAX Op $6850 Office Co-pay $40 Specialist $60 RX: $15/45/85 Specialty Med 30% Max $350/$250 $95.81 $261.10 $269.80 $435.05
2TDK: Anthem Health Keepers Bronze POS Network $5900/ 0% MAX Op $6850 Office Co-pay (First 3 visits $35) then Deductible RX: $15/45/85 Specialty Med 30% Max $350/$500 $78.18 $226.73 $234.54 $383.09
Employee Dental & Vision Rates per pay period. (Bi Weekly)
Plan Options Employee Only Employee & Children Employee & Spouse Employee & Family
Dental and Vision
Dental Plan/ $1500 100/80/50 No waiting period for Preventive & Basic services / 12 month waiting for major services $14.53 $31.81 $29.70 $48.36
Vision Exam co-pay $2 0/ Lenses Replacement 12 Mo Frame replacement 24Mo $130 Frame allowance Contacts $130 Allowance $2.98 $4.84 $5.38 $8.20

    Name (required)

    Email Address (required)

    Phone Number (required)

    Gender (required)
    MaleFemale

    Social Security Number

    Date of Birth

    Mailing Address (street)

    City

    State

    Zip Code

    Date Employed Full Time

    Hours Worked Per Week

    Job Occupation/Class

    Location

    Do you have an eligible spouse or domestic partner or child(ren)?
    YesNo

    Payment Mode
    monthlysemi-monthlyweeklybi- weekly

    Employer Zip

    Employer County

    Eligible Dependent Information (Complete if you are electing benefits for your spouse or domestic partner or children)

    Name
    Date of Birth
    Gender MaleFemale
    Social Security Number
    Relationship SpouseDomestic Partner

    Name
    Date of Birth
    Gender MaleFemale
    Social Security Number
    Relationship ChildFoster Child*Disabled Child

    Name
    Date of Birth
    Gender MaleFemale
    Social Security Number
    Relationship ChildFoster Child*Disabled Child

    Name
    Date of Birth
    Gender MaleFemale
    Social Security Number
    Relationship ChildFoster Child*Disabled Child

    Name
    Date of Birth
    Gender MaleFemale
    Social Security Number
    Relationship ChildFoster Child*Disabled Child

    *If you checked foster child, was the child placed with you by an authorized state placement agency or by order of a court? YesNo

    **When your child, who is developmentally or physically disabled, reaches/exceeds the maximum age, an Application to Continue Disabled Child form must be completed and reviewed to determine eligibility. Is your spouse or domestic partner employed by this company? YesNo

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    Coverage Opt-ins

    Desired Health Plan And Coverage Opt-ins
    2T2W:Anthem Silver PPO $4000 (Employee Only, $121.80)2T2W:Anthem Silver PPO $4000 ($321.79, Employee and Spouse)2T2W:Anthem Silver PPO $4000 (Employee and Children, $311.79)2T2W:Anthem Silver PPO $4000 (Employee and Family, $511.78)2T31:Anthem Health Keepers Silver OAPOS Network $4000 (Employee Only, $95.81)2T31:Anthem Health Keepers Silver OAPOS Network $4000 (Employee and Spouse, $269.80)2T31:Anthem Health Keepers Silver OAPOS Network $4000 (Employee and Children, $261.10)2T31:Anthem Health Keepers Silver OAPOS Network $4000 (Employee and Family, $435.09)2TDK: Anthem Health Keepers Bronze POS Network $5900 (Employee Only, $78.18)2TDK: Anthem Health Keepers Bronze POS Network $5900 (Employee and Spouse, $234.54)2TDK: Anthem Health Keepers Bronze POS Network $5900 (Employee and Children, $226.73)2TDK: Anthem Health Keepers Bronze POS Network $5900 (Employee and Family, $383.09)

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    Dental Coverage Opt-in
    NoneEmployee ($14.53)Employee and Children ($31.81)Employee and Spouse ($29.70)Employee and Family ($48.36)

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    Vision Coverage Opt-in
    NoneEmployee ($2.98)Employee and Children ($4.84)Employee and Spouse ($5.38)Employee and Family ($8.20)

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    Important: You must elect Employee coverage in order to elect the coverage for your dependent(s).

    *If enrolling a Domestic Partner, please attach a separate Declaration of Domestic Partnership/Enrollment Form Addendum (GP60480).

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    Declining Coverage

    Important: If declining any coverage for yourself or any dependent, give reason. Covered under:
    Spouse's or Domestic Partner's Group InsuranceIndividual InsuranceOther Coverage Offered by My EmployerOther

    Please state your other coverage:

    Employee Agreement (Read and sign)

    I understand and agree with the following statements:
    • My dependents are not eligible for coverages I don't have. My dependents, including step and foster children and any over the maximum age, are eligible based on plan provisions but those over the maximum age will be verified when a claim is filed.
    • If I refuse dental coverage, I and my dependents may enroll later but this will affect the level of benefits.
    • If I refuse coverage, I cannot enroll after retirement.
    • If the group policy does not require my contribution, I cannot decline coverage unless the policy indicates otherwise.
    • If the group policy requires my contribution, I authorize my employer to deduct from my pay.
    • I represent all information on this form and attachments is complete and true to the best of my knowledge. They are part of this request for coverage. I agree insurance carrier is not liable for a claim before the effective date of coverage and all policy provisions apply. I have read, or had read to me, the information and my answers on this form. During the first two years coverage is in force, fraud or intentional misrepresentations can cause changes in my coverage, including cancellation back to the effective date.
    • Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, may be guilty of insurance fraud.
    • Explanation of Benefits reflecting claims payments for myself and my dependents will be sent to my home address. I also understand collection of social security numbers for myself and/or my dependents will be used by insurance carrier only as allowed by law.
    • I authorize insurance carrier to release data as required by law. If signed in connection with an application, reinstatement or a change in benefits, this form will be valid two years from the date below. I may revoke authorization for information not yet obtained. I understand data obtained will be used by insurance carrier for claims administration and determining eligibility for life, disability and critical illness coverage. Information will not be used for any purposes prohibited by law.

    A copy of this form will be as valid as the original.

    I declare that the information I have completed on this enrollment form is complete and true. I understand an agent or broker cannot guarantee coverage, revise rates, benefits or provisions without written approval from insurance carrier.

    Digitally Sign and Agree:
    Name:

    I agree.I do not agree.
    Date: