2010 Benefits Enrollment

2010 Benefits Enrollment Form

Please carefully read all of your options.

All the rates shown are per month.

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ELIGIBILITY

1. DO YOU WORK 25+ HOURS A WEEK? YES NO

2. HAVE YOU BEEN EMPLOYED WITH DECISIONHR FOR 45+ DAYS? YES NO

PERSONAL INFORMATION
FIRST NAME: LAST NAME: SOCIAL SECURITY #:
DATE OF BIRTH NAME OF WORKSITE EMPLOYER:
ADDRESS CITY ST ZIP	IS THIS A NEW ADDRESS? YES NO
PHONE NUMBER EMAIL ADDRESS	GENDER MALE FEMALE
YOU PREFER TO BE CONTACT BY PHONE OR EMAIL	ALTERNATE PHONE:

DEPENDENT INFORMATION
	DEPENDENT 1	DEPENDENT 2	DEPENDENT 3	DEPENDENT 4	DEPENDENT 5
FIRST NAME
LAST NAME
SOCIAL SECURITY #
GENDER	FEMALE MALE	FEMALE MALE	FEMALE MALE	FEMALE MALE	FEMALE MALE
DATE OF BIRTH
ADDRESS	Same Other	Same Other	Same Other	Same Other	Same Other
RELATIONSHIP

OPTION 2- PPO DENTAL HI
View Brochure
EMPLOYEE ONLY	$22.98
EMPLOYEE + SPOUSE	$44.12
EMPLOYEE + CHILD(REN)	$57.67
EMPLOYEE + FAMILY	$78.80

OPTION 3- PPO DENTAL LO
View Brochure
EMPLOYEE ONLY	$15.77
EMPLOYEE + SPOUSE	$30.13
EMPLOYEE + CHILD(REN)	$43.48
EMPLOYEE + FAMILY	$57.85

VSP VISION INSURANCE
Rates Are Monthly
YOU WOULD LIKE TO? View Brochure	WAIVE COVERAGE	EMPLOYEE ONLY	$9.88
	DROP COVERAGE	EMPLOYEE + SPOUSE	$15.29
	CHANGE COVERAGE	EMPLOYEE + CHILD(REN)	$15.60
		EMPLOYEE + FAMILY	$25.13

LINCOLN LIFE AND DISABILITY INSURANCE

If you are interested in Life, LTD-Long Term Disability, STD- Short Term Disability; Please click on the following link:

Lincoln Life & Disability Enrollment

NEED ADDITIONAL INFORMATION OR HAVE QUESTIONS AND COMMENTS?
PLEASE TYPE YOUR QUESTIONS OR COMMENTS IN THE BOX BELOW AND THE BENEFITS DEPARTMENT OF DECISIONHR WILL CONTACT 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. EN ESPAÑOL

"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:

Important Enrollment/Change Information

The Medical, Dental, Vision or Supplemental you select during the Open Enrollment Period will be in effect through the next calendar year, January 1, 2010– December 31, 2010. Federal Law limits your ability to change most of your elections outside of Open Enrollment unless you experience a “Qualifying Event”* and the change must be made within 30 days of the event date. Supporting documentation must be submitted within 30-days of qualifying event to the Benefits Department along with the election change.

*Qualifying Event: Obtain other coverage, termination of employment, reduction of hours, divorce/legal separation, death of covered employee/retiree, birth/adoption, Medicare eligibility, ineligibility of dependent child.

For immediate assistance, please feel free to contact us: Phone: 727 572-7331 or Toll Free 1 888 828-5511
Michelle Sovia, Ext. 5257 MSovia@decisionhr.com -OR- Peggy Bucko, Ext. 5230 PBucko@decisionhr.com
Thank You.