EMPLOYEE BENEFIT BROCHURE
SPOUSAL CARVE OUT AFFIDAVIT
INSTRUCTIONS: COMPLETING YOUR ENROLLMENT FORMS
PAGE 1: EMPLOYEE ENROLLMENT
SECTION 1 - EMPLOYEE INFORMATION
- Be sure to fill out all of your demographic information. We will NOT be able to enroll you if there is any missing information.
SECTION 2 - DEPENDENT INFORMATION
- Provide all information for your dependents that you will be covering under the medical plan.
- You do not have to list your dependents if they will not be covered under the medical plan.
SECTION 3 - CHOOSE YOUR PLAN
- If you are covering any dependents under the medical plan, as your employer, we have the right to request proof of dependency. Please do not provide information unless it is requested.
section 4 - Voluntary life insurance
- Enter in the desired amount of coverage.
- If you are waiving select the decline box.
- PLEASE NOTE: If you are electing over the Guaranteed Issue Amount you will need to fill out the EOI Form listed under the Voluntary Life Information on the "New Benefits" page of this website.
Section 5 - Signature & Date
- Enter your signature and Date.
PAGE 2: CONTRIBUTION FORM
sECTION 1 - CONTRIBUTION FORM
- Complete the top section of the Payroll Deduction Form.
- Find the health plan you chose on the Enrollment Form, and check off the corresponding deduction.
- The Payroll Deduction Acknowledgment must match the Enrollment Form, or your payroll deductions will be adjusted to reflect what you have elected on the Enrollment Form.
- If you are waiving coverage, check off "waiver".
- Read the disclosure, sign, and date.
PAGE 3: BENEFICIARY DESIGNATION UNDER GROUP LIFE INSURANCE POLICY
SECTION 1 - CHOOSE WHAT POLICY THE BENEFICIARY DESIGNATION IS FOR
- Be sure to select the box that says "All Policies".
SECTION 2 - GROUP INFORMATION
- Enter in your name under "Name of Insured Person"
- Enter in your Social Security Number under "Insured Person's SSN"
- Enter your Date of birth under "Insured Person's Date of Birth"
SECTION 3 - PRIMARY BENEFICIARIES
- Please fill in all of the required fields when choosing a primary beneficiary
- We suggest that you do not choose a dependent under the age of 18 years old as a beneficiary.
- You can decide the percentage amount that you would like give to each beneficiary.
- 100% to each - This means there will be a chain of custody. Should you pass away the first person that you listed will get 100% of the funds. If that person has passed then 100% will go to the next person that you list.
- 50% to two beneficiaries - This means that the amount will be split 50 / 50 between the two people that you have listed.
- A variation equaling 100% - You can designate as percentage amount to whom ever you list.
SECTION 4 - CONTINGENT BENEFICIARIES
- Please follow the same instructions as the Primary Beneficiaries section.
SECTION 5 - SIGNATURE
- Sign and print your name and the date.
- Have a witness (who is NOT listed in the beneficiaries column) sign and date.
- Please have your spouse sign under the "Spouse's Signature and Consent" if applicable.