2021 Insurance Enrollment - Full-Time Team Members

Form Reason*
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Social Security Number
Phone*
Location*
Supervisor*
Marital Status*
- Married
- Single
Gender*
- Male
- Female

Flexible Savings Account
- I want to contribute to the Flexible Spending Account
- I want to contribute to the Dependent Care Account
- I want my premiums to be withheld pretax, but I do not want to contribute to the Flexible Spending or Dependent Account
- I decline to participate in the Flexible Spending, Dependent Care account, or insurance.
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".
Flex Savings Account Amount*

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.
Dependent Care Account*

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.
HSA Contribution Amount*

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.
Limited FSA

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.

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.
Cont. Beneficiary Designation #1
First Middle Last
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.
Relationship to Cont. Beneficiary #1
Cont. Beneficiary #1 Social Security Number
% of benefit to Cont. Beneficiary #1

You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
Cont. Beneficiary Designation #2
First Middle Last
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.
Relationship to Cont. Beneficiary #2
Cont. Beneficiary #2 Social Security Number
% of benefit to Cont. Beneficiary #2

You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
Cont. Beneficiary Designation #3
First Middle Last
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.
Relationship to Cont. Beneficiary #3
Cont. Beneficiary #3 Social Security Number
% of benefit to Cont. Beneficiary #3

You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
Blank Page
If this page is blank, just click on next to be taken to the next page.

Pet Insurance*
- Elect Pet Insurance - I understand that I must contact Nationwide directly to enroll or cancel this benefit.
- Decline Pet Insurance

Norton LifeLock
- Employee Only
- Family
- No Coverage
Norton LifeLock Plan Options
- Essential
- Premier

Consent*
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.

I understand.
Must cover amount each payroll*
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 agree.
Notice, Agreement, and Signature*
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.

I certify by my signature below that I have completed this form to the best of my knowledge, and I agree to all the above statements.
Signature*

2021 Insurance Enrollment Form - Full-Time Team Members

Step 1 of 11

Spouse's Information

Dependent's Information

Primary Beneficiaries

Contingent Beneficiaries