Presentation on theme: "Rights & Disclosures This information is intended to be shared by employees with their spouse and dependents. 2014 Employee Benefits Plan Overview www.westplattebenefits.info."— Presentation transcript:
Rights & Disclosures This information is intended to be shared by employees with their spouse and dependents Employee Benefits Plan Overview
Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward you or your dependents other coverage). However, you must request enrollment within 30 days after you or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or to obtain more information contact Bukaty Companies at Notice of pre-existing condition limitations Your plan may impose a pre-existing condition exclusion. This means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received within a 6-month period. Generally, this 6-month period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the 6-month period ends on the day before the waiting period begins. The pre-existing condition exclusion does not apply to pregnancy or to a child who is under the age of 19. This exclusion may last up to 12 months (18 months if you are a late enrollee) from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. However, you can reduce the length of this exclusion period by the number of days of your priorcreditable coverage. Most prior health coverage is creditable coverage and can be used to reduce the pre-existing condition exclusion if you have not experienced a break in coverage of at least 63 days. To reduce the 12-month (or 18-month) exclusion period by your creditable coverage, you should give us a copy of any certificates of creditable coverage you have. If you do not have a certificate, but you do have prior health coverage, we will help you obtain one from your prior plan or issuer. There are also other ways that you can show you have creditable coverage. Please contact us if you need help demonstrating creditable coverage. All questions about the pre-existing condition exclusion and creditable coverage should be directed to Bukaty Companies at Plan participants may be subject to more favorable limitations based on applicable state law in which the employer group is located. Womans Health and Cancer Rights Act (WHCRA) of 1998 If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Womens Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: - All stages of reconstruction of the breast on which the mastectomy was performed; - Surgery and reconstruction of the other breast to produce symmetrical appearance; - Prostheses; and - Treatment of the physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. See your Plans medical summary for deductibles and coinsurance details. If you would like more information on WHCRA benefits, call your Plan Administrator. Do you know that your plan, as required by the Womens Health and Cancer Rights Act (WHCRA) of 1998, provides benefits for mastectomy- related services including all stages of reconstruction and surgery to achieve symmetry between breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Call Bukaty Companies at for more information. Keep Us Informed of Status Changes It is very important that you keep your Plan Administrator informed of address changes and other personal data changes for you and/or dependents who are or may become qualified beneficiaries on any of the companys group benefits. Changes should be reported to the Plan Administrator. COBRA Rights In the Event You Lose Your Health (Medical/Dental/Flex) Coverage… A group health plan is required to offer COBRA continuation coverage to you, your spouse and your dependents enrolled in the Plan when a qualifying event occurs that causes loss of group health coverage. Coverage may be available for 18 months up to a maximum of 36 months, depending upon the qualifying event. The employer is required to notify the Plan if the qualifying event is: - Termination (for any reason other than gross misconduct) or reduction in hours of employment of the covered employee - eligible for up to 18 months of continuation coverage - Death of the covered employee - eligible for up to 36 months of continuation coverage - Covered employee becomes entitled to Medicare - eligible for up to 36 months of continuation coverage depending upon date of Medicare entitlement The covered employee or one of the qualified beneficiaries is responsible for notifying the Plan Administrator within 60 days of the occurrence if the qualifying event is: - Divorce or legal separation - eligible for up to 36 months of continuation coverage - A childs loss of dependent status under the Plan - eligible for up to 36 months of continuation coverage
Disability Extension If you or anyone in your family covered under the Plan is determined by the Social Security Administration (SSA) to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of coverage for a total of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. To obtain the extended coverage, a copy of the SSA disability determination must be received by the Plan Administrator within 60 days after the determination is issued and within the individuals first 18 months of continuation coverage. If SSA determines later the individual is no longer disabled, that individual must notify the Plan Administrator within 30 days after the date of the second determination. Second Qualifying Event If while on 18 months of continuation coverage, family members enrolled in the Plan experience another qualifying event, they may be entitled to an additional 18 months of coverage, for a maximum of 36 months. The extension may be granted if the employee or former employee dies, becomes entitled to Medicare or gets divorced or legally separated, or if the dependent child loses dependent status, but only if the events would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. When responsibility for notification rests with the covered employee or qualified beneficiary, notice of the qualifying event must be made within 60 days of the occurrence to the companys Plan Administrator. A detailed explanation of COBRA rights and procedures is available in the Plans Summary Plan Description. Lifetime limit The lifetime limit on the dollar value of benefits under your group health plan no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals have 30 days from the date of this notice to request enrollment. For more information contact Bukaty Companies at Medicaid and the Childrens Health Insurance Program (CHIP) Offer Free Or Low-Cost Health Coverage To Children And Families If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer- sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial KIDS NOW or to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer- sponsored plan.www.insurekidsnow.gov Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employers health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employers plan. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. You should contact your State for further information on eligibility. KANSAS – Medicaid MISSOURI – Medicaid Website: Phone: Phone:
Employee Benefits Summary We recognize that our employees are our most valuable resource and therefore, your benefits program is extremely important to West Platte School District. Therefore, it is our pleasure to offer our benefits-eligible employees a variety of solutions to help address your benefit needs, as well as the needs of your families. Our employees continue to be the driving force behind our past success and position us well for the future. Thank you for your ongoing commitment as we strive to be the best employer in our industry. We are proud to include all of you as part of the West Platte School District family. This summary of benefits is intended only to highlight your benefits and should not be relied upon to fully determine coverage. This plan may not cover all your health care expenses. Please refer to the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. LaNae Solberg Account Manager m m Scott Hefner Vice President m m LaNae assists current and new business clients with day-to-day issues such as billing or claims questions and provides continued customer service. Scott oversees all aspects of your employee benefits program. Kharlysa Armstrong New Business/Renewal Specialist Kris Hewlett Account Coordinator m m Kharlysa is responsible for obtaining carrier quotes, preparing spreadsheets, and assisting groups through the enrollment and underwriting processes. Kris assists with the new business and submission process and provides continued customer service. Bukaty Companies Roe Ave. Leawood, KS Phone: Fax: w.bukaty.com Bukaty Companies Service Team
BLUE KC CHOICES Making the right choices and becoming more knowledgeable about your plan options helps you be a better health care consumer. The plan you choose should simply be the one youre most comfortable with – a plan that fits your health needs, budget, and personal preferences. No matter which plan you enroll in, youll have the assurance of some financial protection against any major, unexpected medical expenses that are covered by your plan. Your choices include all of the plans briefly described below: HMO - With an HMO (Health Maintenance Organization), theres no deductible. Your share of the costs includes copayments for many services. You choose a primary care physician (PCP) who will provide most of your care and recommend specialists as needed. To visit a specialist who participates in the Blue Care Network, simply select the specialist and make an appointment. No referral is required. An HMO generally does not cover any services from non-participating providers, except for emergencies. The HMO plan utilizes the Blue Care Network. Preventative care covered at 100%. Higher premiums/no deductible. PPO - A PPO (Preferred Provider Organization) allows you to see participating and non- participating providers. The PPO plans utilize the Preferred-Care Blue Network. In-network preventative care covered at 100%. The District offers you Three PPO plans to choose from – the $500 PPO, $1,500 PPO and the $2500 PPO. The $1500 and $2500 PPO include a Health Reimbursement Agreement. HDHP PPO - A HDHP (High Deductible Health Plan) PPO allows you to see participating and non- participating providers. This medical plan option consists of two parts – the HDHP which provides health insurance coverage through Blue KC and the Health Savings Account (HSA). The HDHP utilizes the Preferred-Care Blue Network. In-network preventative care covered at 100%. Lower premium/higher deductible.
Medical: BlueCross BlueShield of KC You are eligible to participate in the medical benefit plan on the first of the month following your hire date. Eligible dependents may also participate; eligible dependents include your legal spouse and/or dependent child(ren) age 26 and under. The following table will give you an overview of how the plan works and what your responsibilities are. For questions concerning your medical benefits, a claim, to identify a network provider, or questions concerning your prescription drug coverage please contact BlueCross BlueShield of Kansas City or visit Rates Per Pay Period (24) Employee OnlyEmployee + SpouseEmployee + Child(ren)FamilyFamily Employee Pays$21.11$293.48$241.48$ Preferred Care Blue (PPO Low)Network Out of Network Deductible - Individual/Family (per cal. year)$500/$1,500 Out-of-Pocket max. - Individual/Family (plus deductible)$2,000/$6,000$4,500/$13,500 Co-insurance80% 60% Office Visit$25 copay Office Visit Only Ded. + Coins. Routine Preventive Care100%Ded. + Coins. Generic – Preferred – Non-Preferred$12 - $45 - $70$12 - $45 - $70+50% Mail Order Pharmacy (102 day supply)$30 - $ $175 $30 - $ $175+50% Urgent Care$25 copay Office Visit Only Ded. + Coins. Inpatient Hospital CareDed. + Coins. Outpatient Hospital CareDed. + Coins. Emergency Services$100 + Ded. + Coins.$100 + Ded. Coins. Vision$20 copay $20 copay ($45 ben max) Chiropractic Services $25 copay Office visit only Ded. & Coins. Lifetime MaximumUnlimited Rates Per Pay Period (24) Employee OnlyEmployee + SpouseEmployee + Child(ren)FamilyFamily Employee Pays$28.54$309.08$255.52$ Blue Care ( HMO)Network Deductible - Individual/Family (per cal. year)N/AN/A Out-of-Pocket max. - Individual/Family (plus deductible)$1500 per person Co-insuranceCopays Office Visit$25 ($50 Spec.) Routine Preventive Care100% Generic – Preferred – Non-Preferred$12 - $45 - $70 Mail Order Pharmacy (102 day supply)$30 - $ $175 Urgent Care$50 copay Inpatient Hospital Care$300/day 5xs Outpatient Hospital Care$300 copay Emergency Services$100 copay Vision$20 copay Chiropractic Services No copay Lifetime MaximumUnlimited
$175+50% RRates Per Pay Period (24) EmEmployee OnlyEmployee + SpouseEEmployee + Child(ren) Family Employee Pays$0$0$201.55$163.07$ Health Reimbursement Account (HRA) – West Platte covers the last $1,050 of deductible one per employee per year. Preferred Care Blue PPO (High Deductible)NetworkOut of Network Deductible – Individual/Family (per cal. year)$2,500/$7,500 Out-of-Pocket max. – Individual /Family (plus deductible)Deductible$7,500/$12,500 Co-insurance100%80% Office Visit$40 copayDed. & Coins. Routine Preventive Care100%Ded. & Coins. Generic – Preferred – Non-Preferred$12 - $45 - $70$12 - $45 - $70+50% Mail Order Pharmacy (102 day supply)$30 - $ $175$30 - $ $175+50% Urgent Care$40 Office Visit OnlyDed. & Coins. Inpatient Hospital CareDeductibleDed. & Coins. Outpatient Hospital CareDeductibleDed. & Coins. Emergency ServicesDeductible Vision$20 copay$20 copay ($45 ben max) Chiropractic Services$40 copay Office Visit Only Ded. & Coins. Lifetime MaximumUnlimited Rates Per Pay Period (24) Employee OnlyEmployee + SpouseEmployee + Child(ren)FamilyFamily Employee Pays$0$220.68$175.97$ Health Reimbursement Account(HRA) – West Platte covers last $325 of the deductible. (one per employee per year) Preferred Care Blue (PPO High)Network Out of Network Deductible - Individual/Family (per cal. year)$1,500/$4,500 Out-of-Pocket max. - Individual/Family (plus deductible)$2,000/$6,000$5,500/$16,500 Co-insurance80% 60% Office Visit$35 copay Office Visit Only Ded. + Coins. Routine Preventive Care100%Ded. + Coins. Generic – Preferred – Non-Preferred$12 - $45 - $70$12 - $45 - $70+50% Mail Order Pharmacy (102 day supply)$30 - $ $175 $30 - $ Urgent Care$35 Office Visit Only Ded. + Coins. Inpatient Hospital CareDed. + Coins. Outpatient Hospital CareDed. + Coins. Emergency Services$100 Ded. + Coins$100 Ded. + Coins. Vision$20 copay $20 copay ($45 ben max) Chiropractic Services$35 copay Office Visit Only Deductible Lifetime MaximumUnlimited
$12/$45/$70+50% $30/$112.50/$175+50% 2,500 HDHP with Health Savings Account This medical plan consists of two parts: 1. $2,500 HDHP: provides health insurance coverage though Blue KC. 2. Health Savings Account (HSA): a special, tax exempt account used in conjunction with the high deductible health plan. This account provides funding to pay for qualified medical expenses NOT covered by the insurance. The HSA is provided by UMB Bank. The $2,500 HDHP utilizes the Preferred-Care Blue Network. In Network Preventative Care is covered at 100% with no deductible or copayment. Includes a $2,500 individual /$5,000 Family deductible. Health Savings Account is owned by YOU and is portable in the event you change employers. Funds contributed to your HSA are not subject to federal income tax at the time of deposit. HSA has no use it or use it rule. Interest or earnings that accumulate in your HSA are not subject to federal income tax. Funds withdrawn from your HSA to pay for qualified medical expenses-at any time- are not subject to federal income tax. In the event of disability or at the age of 65, HSA funds can be withdrawn for any purpose without penalty. HSA funds can be used to help meet and pay for your deductible. If you enroll in the $2,500 HDHP, the District will contribute $90 per month to your HSA for a total annual contribution of $1,080. How Much Can I Contribute? IRS limits the annual maximum contribution. The maximum annual contribution (between the Districts contribution and your own contribution) for 2014 is: $3,300 individual / $6,550 family - Catch-up contributions of $1,000 are available for employees 55 and over. Rates Per Pay Period (24) Employee OnlyEmployee + SpouseEmployee + Child(ren)FamilyFamily Employee Pays$0$198.83$160.87$ Health Savings Account (HSA) – West Platte contributes $90 per month per employee Preferred Care Blue PPO ( Blue Saver HSA Plan)Network Out of Network Deductible - Individual/Family (per cal. year)$2,500/$5,000 Out-of-Pocket max. - Individual/Family (plus deductible)Deductible$7,500/$15,000 Co-insurance100% 80% Office VisitDeductible Ded. + Coins. Routine Preventive Care100%Ded. + Coins. Generic – Preferred – Non-PreferredDeductible then 100% Ded. then Mail Order Pharmacy (102 day supply)Deductible then 100% Ded. Then Urgent CareDeductible Ded. + Coins. Inpatient Hospital CareDeductibleDed. + Coins. Outpatient Hospital CareDeductible Ded. + Coins. Emergency ServicesDeductible Vision$20 copay $20 copay ($45 ben max) Chiropractic ServicesDeductible Ded. + Coins. Lifetime MaximumUnlimited
Dental: BlueCross Blue Shield of KC Maintaining good dental health by getting regular checkups may prevent you from having major expenses later. The dental plan covers routine checkups – and just about any other type of dental work you might need. You are eligible for benefits on the first of the month following your hire date. Eligible dependents may also participate. Eligible dependents include your legal spouse who does not have coverage available through their employer and/or dependent child(ren) under the age of 26 not eligible as a subscriber under another dental plan. To identify participating premier dentists, you may call BlueCross BlueShield of Kansas City or visit Vision: Eye Med Annual eye exams are important to your overall health. During your eye exam, a vision doctor will look for vision problems and signs of other health conditions like diabetic eye disease, high blood pressure, and high cholesterol. You are eligible to participate in the medical plan on the first of the month following your hire date. Eligible dependents may also participate. Eligible dependents include your legal spouse and/or dependent child under age 19/25 full time student. To identify participating doctors, you may call EyeMed at or visit their website at ess. Employee Rates (24)Employee Only Employee + 1 FamilyFamily Vision Rates$ 3.01 $4.21 $ 7.26 EyeMed Vision NetworkNetworkNon-Network Eye Exam (once every 12 months)100% coveredUp to $45 Lenses: (once every 12 months) Single/Bifocal/Trifocal$15 copay (standard plastic lenses) Up to $45/$65/$85 Standard Progressive/Lenticular$15 copay (standard plastic lenses) Up to $85/$125 Frames: (once every 24 months) $120 allowance & 20% off after allowance over $120 $47 Contacts Lenses Elective: (once every 12 months) In lieu of lenses and frames $120 allowance; Up to $60 copay + 15% off balance over $120 Up to $105 Lasik & PRK (Photoretractive Keratectomy) Members also receive 15% off retail price or 5% off promotional price for Lasik or PRK from the US Laser Network, owned and operated by LCA Vision. For a location near you and the discount authorization, please call LASER6. Rates Per Pay Period (24)Employee OnlyEmployee + SpouseEmployee + Child(ren)FamilyFamily Dental Rates$6.70$20.10$22.55$37.80 Preferred Care Dental – Blue Dental Plus Deductible$50 per person / Maximum of $150 per family Annual Maximum$1,500 per covered person Preventive Services (not subject to deductible) Covered at 100% Network Providers (80% Non-Network) Basic ServicesCovered at 80% Network Providers (60% Non-Network) Major ServicesCovered at 50% Network Providers (40% Non-Network) * 12 month wait
Basic Life/AD&D: USAble Coverage is provided by the company and is effective on the first of the month following your hire date. Now is a good time to update beneficiary information. Voluntary Term Life/AD&D: USAble You also have the option of purchasing additional life insurance for yourself, your spouse, and your eligible dependents. at the employees retirement. Voluntary Life Rates – WITH PORTABILITY AGES Rates for Employees: Per $10,000 Units Blended 16-34$ $ $ $ $ $ $ $ $ $ $ $ $ 1, $ 2, SPOUSESPOUSEPremiums determine by spouses age. CHILDREN $10,000 Coverage - $3.00 Monthly Premium $5,000 Coverage - $1.50 Monthly Premium Benefit Benefit schedule Employees may choose to purchase benefits in $10,000 increments to a maximum of $300,000 Spouse - $10,000 increments to a maximum of $150,000 Children – Birth to 6 months = $1,000; Age 6 months to less than age 26 = $5,000 or $10,000 Guarantee Issue Employee coverage up to $100,000 (no guarantee issue over age 69) Spouse coverage of $30,000 through age 69. Child coverage of $5,000 or $10,000 Age Reduction Employee and spouse benefits reduce by 35% at age 65, by 50% at age 70, and terminate Benefit Life/AD&D Amount$25,000 Reduction ScheduleBenefits reduce to 35% at age 65; to 50% at age 70. Coverage terminates at retirement.
Change 2014 West Platte School District Enrollment Form Employee Information EmployerEmployees Name Smoker Yes No Address Street City State Zip CodeGenderMarital Status Male Female Single Married SSNDate of Birth _/_ _/_ Date of Hire / / $ Hourly Salary Home Phone ( ) AddressPosition# Hours/Week Open Enrollment New Hire Qualifying Event: Dependent Information *Include only if electing dependent coverage Name Add Delete SSNDate of Birth _/_ _/_ Gender Male Female Relationship Name Add Delete SSNDate of Birth _/_ _/_ Gender Male Female Relationship Name Add Delete SSNDate of Birth _/_ _/_ Gender Male Female Relationship Name Add Delete SSNDate of Birth _/_ _/_ Gender Male Female Relationship Name Add Delete SSNDate of Birth _/_ _/_ Gender Male Female Relationship Coverage Options Benefit Employee Only Employee + Spouse Employee + Child(ren) FamilyFamily Waive/No Medical: BCBS of KC HMO PCP# PCP# PCP# PCP# Medical: BCBS of KC PPO Low ($500 Ded.) PPO High ($1500 Ded.) PPO High HRA ($2500 Ded) PPO Blue Saver HSA($2500 Ded)* *must complete additional documentation Dental: BCBS KC Vision: EyeMed / Vol. Life: USAble LifeAdditional Form Employee Signature I hereby authorize my employer to deduct the appropriate premium contributions from payroll based on my benefit election choices. Employee Signature: Date: _/_ /
Your Employer's group contract provides coverage that may contain limitations based on whether a condition is considered preexisting. For Kansas groups and Kansas residents, any condition (whether physical or mental) for which medical advice, diagnosis, care or treatment was recommended or received within the 90 day period prior to the enrollment date is considered a preexisting condition, and your Employer's group contract excludes coverage for these specific preexisting conditions for 90 day from the enrollment date. For Missouri groups, any condition (whether physical or mental) for which medical advice, diagnosis, care or treatment was recommended or received within the 6 month period prior to the enrollment date is considered a preexisting condition, and your Employer's group contract excludes coverage for these specific preexisting conditions for 12 months from the enrollment date. However, your Employer's group contract will provide credit for preexisting conditions if you were previously covered under creditable coverage. The period of any preexisting condition exclusion that would otherwise apply to a person will be reduced by the number of days of creditable coverage the person has as of the enrollment date. In order to receive credit toward the preexisting condition exclusion period, you must provide copies of the certificates of Creditable Coverage or other acceptable proof of coverage from the prior plan(s) or the following information for the verification of prior creditable medical coverage you or any listed dependents currently have, or previously had, including continuation of coverage. You have the right to request a Certificate of Creditable Coverage from your prior plan or insurer. To request assistance in obtaining a Certificate of Creditable Coverage from a prior plan or insurer, please contact Blue Cross and Blue Shield of Kansas City. Should you need additional information or assistance regarding any preexisting condition exclusion, please contact our Member Services Department at (816) Insurance Company Name: Name as listed on policy: Name(s) of person(s) covered in prior plan: Effective Date: /_ /_ Termination Date: /_ _/ Pre-Existing Conditions: If you are enrolling in the PPO products, please complete the following to receive Creditable Coverage. Only effects enrollees with a lapse of coverage more than 63 consecutive days.
USAble Life P.O. Box 1650 · Little Rock, Arkansas V OLUNTARY L IFE E NROLLMENT F ORM (P LEASE P RINT ) (Completed by I represent that the information provided above is true and correct. I understand that if I am not actively at work on the effective date of my coverage, my insurance will not begin until the day I return to work. For coverage I have declined, I understand that if I choose to enroll at a later date, Evidence of Insurability may be required. If the Plan provides that any contributions be made by me, I authorize my employer to deduct them from my pay. Warning: It is or may be a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company or other person. Penalties may include imprisonment, fines, and denial of insurance benefits in accordance with applicable state law. Employees SignatureDate VGTL-APP (5-09) Date Received - Home Office New Enrollee Change Decline coverage Group #: Employer: If Evidence of Insurability (EOI) is required, please submit the Evidence of Insurability form along with this enrollment form to us. Employers Name S ECTION I. E MPLOYEE I NFORMATION Employees Legal Name (First, MI, Last)Social Security No. Home AddressCityStateZipZipTelephone No. Date of BirthGender M FSalary $ Weekly Monthly Annual Occupation (Be Exact)Dept/Location Hours Worked WeeklyDate Employed Full-time P LAN I NFORMATION - Ask your employer for the details about the cost, if any, and whether you will be required to complete Evidence of Insurability (EOI). S ECTION II. V OLUNTARY – S EE I NSTRUCTIONS ON R EVERSE OR P AGE 2 Complete this Section if applying for these coverages. Evidence of Insurability may be required. Add New Delete Increase Existing Decrease Existing Total Amount of Coverage Premium Employer) Voluntary Group Life: Employee Yes No SpouseYes No ChildrenYes No Dependents to be coveredGenderRelationshipSocial Security No.Date of Birth M F MF MF MF MF Have you or your spouse (if applying for coverage) used tobacco products in the past year? Employee Spouse Yes No Are you actively at work on the date of this application?YesNo S ECTION III. E MPLOYEE B ENEFICIARY D ESIGNATION Check if Change Only This will revoke any existing beneficiary designations you may have for these benefits. PRIMARY BENEFICIARY(IES) (Will receive proceeds if living at death of Employee): Name (Last, First, MI)AddressSSNBirthdateRelationshipPercentage Total must equal 100% = CONTINGENT BENEFICIARY(IES) (Will receive proceeds if Primary Beneficiary(ies) are not living): Name (Last, First, MI)AddressSSNBirthdateRelationshipPercentage Total must equal 100% =
Initial Enrollment –Adding Coverage: Check Yes by each coverage you want. Check No by each coverage you do not want. If you checked Yes by a coverage, check the Add New box, and complete the Total Amount of Coverage for which you are applying. For Example, you are applying for: Voluntary Group Life: $50,000 on yourself, $20,000 on your spouse, and no coverage on your children Evidence of Insurability may be required. How To Change or Delete Coverage: If you are changing any of your coverage, please complete the information for all of the coverage you have, so that we are sure we have everything correct. Be sure to check the appropriate Add, Delete, Increase, or Decrease box. For Example, you currently have: Voluntary Group Life: $60,000 on yourself, $30,000 on your spouse, and $10,000 coverage on your children You want to change your coverage to: Voluntary Group Life: $100,000 on yourself (increase), $20,000 on spouse (decrease), and no coverage for children (delete) Evidence of Insurability may be required. VGTL-APP (5-09) S ECTION II. V OLUNTARY C OVERAGE ( S ) Add Increase Decrease New Delete Existing Existing Total Amount of Coverage Premium (Completed by Employer) Complete this Section if applying for these coverages. A. Voluntary Group Life: Employee YesNo $100,000 SpouseYesNo $20,000 ChildrenYesNo S ECTION II. V OLUNTARY C OVERAGE ( S ) Add Increase Decrease New Delete Existing Existing Total Amount of Coverage Premium (Completed by Employer) Complete this Section if applying for these coverages. A. Voluntary Group Life: Employee YesNo $50,000 SpouseYesNo $20,000 ChildrenYesNo INSTRUCTIONS – How to Complete Section II