2008 Benefits

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DecisionHR.com

Do you qualify for Benefits?

Do you work 25+ hours per week? Yes No
Have you been employed with DecisionHR for at least 45+ days? Yes No
What is the name of your Worksite Employer?

If you have answered "No" to any of these questions, you do not qualify for benefits.

*Personal Information:*
	First Name:	Last Name:	Social Security Number:
	Gender: Male Female	Date of Birth: Email Address:
	Is this a new address? Yes No	Address:	City:
	State:	Zip	Phone Number:

Aetna SRC Limited Medical Insurance
Rates shown are monthly You would like to?

Add Coverage (Please make your selection below. First complete the Beneficiary Information)

Waive Coverage

Beneficiary Information: Required for Aetna SRC Coverage (Policy includes a Life Insurance Benefit)	Option 1 View brochure		Option 2 View brochure
Name:	Employee Only	$65.16	Employee Only	$91.96
Relationship:	Employee + 1	$153.72	Employee + 1	$220.96
Social Security #:	Employee + Family	$218.04	Employee + Family	$313.00

Assurant Dental Benefits- 3 Options Available: DMO,PPO Hi or PPO Lo
(You many only enroll in one, please read all brochures prior to making your election)

Assurant Dental DMO Coverage- Only Available to residents of Florida, Georgia and Texas.
Rates Shown Are Monthly

You would like to?
(Please select one)

Add Coverage (Please select your coverage below.)

Waive Coverage

Rates shown are monthly (A DMO Facility# is Required)

FL To view brochure, click "here"		GA To view brochure, click "here"		TX To view brochure, click "here"
Employee	$12.97	Employee	$10.15	Employee	$10.74
Employee + Spouse	$21.05	Employee + Spouse	$17.18	Employee + Spouse	$17.29
Employee + Child(ren)	$28.50	Employee + Child(ren)	$23.82	Employee + Child(ren)	$23.28
Employee + Family	$33.42	Employee + Family	$28.12	Employee + Family	$27.27
DMO Facility #		DMO Facility #		DMO Facility #

Assurant Dental PPO Coverage- There are two options available for PPO Coverage.
Rates Shown Are Monthly

PPO Coverage is available to all States. Please select one.

PPO High To view brochure, click "Here"
Employee	$22.98
Employee + Spouse	$44.12
Employee + Child(ren)	$57.67
Employee + Family	$78.80

PPO Lo To view brochure, click "Here"
Employee	$15.77
Employee + Spouse	$30.13
Employee + Child(ren)	$43.48
Employee + Family	$57.85

VSP Vision Benefits : Available in all States

Rates Shown Are Monthly

To view brochure, click "here"

You would like to?(Please select one)	Add Coverage (Please select your coverage)
	Waive Coverage

Employee	$8.24
Employee + Spouse	$12.75
Employee + Child	$13.01
Employee + Family	$20.96

Dependent Information: Please enter all your dependent's information

Dependent 1

Dependent 2

Dependent 3

Dependent 4

Dependent 5

First Name:

Last Name:

Social Security #:

Gender:

Date of Birth:

Address:

Same

Other

Same

Other

Same

Other

Same

Other

Same

Other

Relationship:

Dental Facility:
Required for DMO

Colonial Supplemental Insurance:	To view Colonial products available, click "here"
I am not interested in Colonial Supplemental Insurance at this time:
Please have a Colonial Representative contact me
What would be the phone number and best time to contact you?

Additional Information or Questions and Comments?
Please type the information in the box below. The Benefits Department of DecisionHR will contact you.

For immediate assistance, please feel free to contact us: Phone: 727 572-7331 or Toll Free 1 888 828-5511
Michelle Sovia, Ext. 257 MSovia@decisionhr.com -OR- Peggy Bucko, Ext. 230 PBucko@decisionhr.com
Thank You.

Employee Salary Reduction Agreement:

Due to Federal Tax Law, IRC Section-125, an election to pay for insurance benefits with pre-tax deductions are irrevocable for one year, unless you have a qualifying event, i.e. termination of employment, reduction in hours, divorce/legal separation, birth/adoption, other coverage, etc.

"I hereby authorize DecisionHR to reduce my gross salary as directed, act as my agent and to establish payroll deductions for the benefit coverage indicated on this application. I also acknowledge that I have reviewed the detailed plan description and all plan exclusions and limitations prior to the signing of this agreement."

Once you submit this form, this becomes a binding contract.

Full Name:

2008 Benefits Enrollment Form