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2021 Insurance Enrollment Form - Full-Time Team Members

Step 1 of 11

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  • Enter the name of your Primary Care Physician. You must be a current patient. If left blank one will be selected for you. You may change this at any time.
  • Spouse's Information

  • Must be a current patient. Otherwise, one will be selected for you. This may be changed at any time.
  • Dependent's Information

  • Must be a current patient. Otherwise, one will be selected for you. This may be changed at any time.
  • Must be a current patient. Otherwise, one will be selected for you. This may be changed at any time.
  • Must be a current patient. Otherwise, one will be selected for you. This may be changed at any time.
    If you don't want the flex plan, but elected Health, Dental, or Vision please mark the "I want my premiums to be withheld pre-tax".
  • Please indicate the annual amount you want to contribute in the FSA. The maximum amount is $2,750. The year runs 9/1/21-8/31/22. Note - this election may not be changed without a qualifying event. By electing the FSA you understand that pre-tax deductions will be made from your paycheck in equal amounts per pay period. Due to COVID, rules were changed for 2021 and 2022 to allow you to roll over any unused funds to the next year.
  • Please indicate the annual amount you want to contribute in the Dependent Care Account. The maximum is $2,500 ($10,500 for Married filing jointly). This is to pay for childcare while you are at work. Please consult your Accountant as you cannot participate in BOTH the Dependent Care Account and take the Childcare Tax credit when your file your taxes at year-end.
  • Please enter the amount you want to contribute to the Health Savings Plan (HSA) for the year. We will divide this amount by 26. If you don't want to contribute any, enter $0.00. IRS Limit is $3,600 individual, $7,200 Family. Over 55 can elect an additional $1,000.
  • If you wish to add funds into the Limited FSA for Dental and Vision. Please enter the annual amount here. The limit is $2,750.
    Note, if you are new to insurance and you decline now, you will have to submit medical information to underwriting to purchase life insurance in the future. If you have been on life insurance for 12 months, you may increase your insurance by $10,000 with no medical underwriting.
    You must purchase voluntary life for yourself in order to purchase for your spouse. You may purchase up to 1/2 of your voluntary life insurance in $5,000 increments.
    You must purchase voluntary life for yourself to purchase for your child(ren). You are eligible to enroll your dependents for voluntary life insurance in increments of $2,500 to a maximum of $10,000. Infants aged 14 days to 6 months will be covered for a flat $1,500 max. Cost is $0.50 per unit ($2,500). So $2,500=$0.50 per month, $5,000=$1.00 per month, etc.
  • Primary Beneficiaries

    You may change your beneficiary at any time by contacting HR.
  • Please complete this section for naming the beneficiary of your life insurance and AD&D, including the $25,000 that is included with your health insurance.
  • You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
  • Please complete this section for naming the beneficiary of your life insurance and AD&D, including the $25,000 that is included with your health insurance.
  • You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
  • Please complete this section for naming the beneficiary of your life insurance and AD&D, including the $25,000 that is included with your health insurance.
  • You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
  • Contingent Beneficiaries

    This is the beneficiary that gets the funds if something happened to you AND the primary beneficiaries. You do NOT have to name a contingent.
  • Please complete this section for naming the beneficiary of your life insurance and AD&D, including the $25,000 that is included with your health insurance.
  • You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
  • Please complete this section for naming the beneficiary of your life insurance and AD&D, including the $25,000 that is included with your health insurance.
  • You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
  • Please complete this section for naming the beneficiary of your life insurance and AD&D, including the $25,000 that is included with your health insurance.
  • You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
    Reason for Declining Health Insurance
    You must click this box agreeing with the statement if you are declining coverage.
    Reason for Declining Health Insurance. Only complete if applicable.
    Only complete if applicable, if no dependent children, leave blank.
  • I have been notified of my opportunity to purchase the above reference insurance. I understand that if I decline at this time for any of these coverages, that I will be unable to enroll later without a qualifying event (i.e. marriage, the birth of a child, etc.) until open enrollment in August 2022. In addition, my coverage elections on this form cannot be revoked or modified during the year unless I have a qualifying change in status as defined by the IRS.
  • If I elected any coverage and my paycheck is not sufficient to cover my premiums, I agree to pay SCC Accounting before the next Friday.
  • I hereby agree to have the above-elected contributions withheld from my paycheck. I give permission to the health plan I select to obtain and/or examine my medical records (and/or those of my dependent(s)) from any health care practitioner or institution in which care is provided while a member, to the extent permitted by law, and I understand the benefits and agree to the provisions as described in the Plan document.
© 2017 Stan Clark Companies
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