Group Enrollment Processing. In order to ensure proper processin g of your applications, please read the following instructions carefully.

Transcription

1 Dergalis ASSOCIA TES Group Enrollment Processing In order to ensure proper processin g of your applications, please read the following instructions carefully. 1) Once you have selected the plan(s) in which you wish to enroll, print and complete the corresponding application(s). 2) Make sure you have signed and completed the application(s) in their entirety. Check them for any errors or missi ng information. 3) Review, complete and sign the Automatic Deduction Agreement form. 4) Make a photocopy of your voided check for the account from which you would like the premium deduction to take place and include it with your forms. Remember, all bank account deductions will take place on the 1st business day of each month. If we are unable to draft your account on this day, you may be subject to fees as outlined in the Automatic Deduction Agreement. 5) Fax your application with the Automatic Deduction Agreement and the voided check to the Insurance Department fax number shown below. We MUST have all applications by the posted due date or coverage cannot become effective! Please call us with any questions you have during the enrollment process. Group Insurance P: (888) , toll free P: (856) , direct F: (856) E: insurance@agentbenefits.ne t Fax all finished paperwork to: ATTN: Group Insurance (856)

2 Q: Must I take all of the benefits? A: No, each benefit can be purchased individually. Frequently Asked Questions Q: Will I get another oppor tunity to enroll if I decline to take coverage now? A: Once a year, the Group Dental and Vision plans will have an Open Enrollment period. However, the Group Disability and Life Insurance will NEVER be offered again on a Guaranteed-Issue basis. While you can apply at a later date, limited medical underwriting will be required and the carrier will have the right to decline you coverage based on the results. Q: I currently have other coverage for Dental and Vision. If I lose that coverage, could I participate in your program? A: Yes, you will have the oppor tunity to enroll in the Dental or Vision plan within 30 days of a qualifying life event such as birth, death, divorce or loss of coverage. For more information on what constitutes a qualifying life event, please contact our office. Q: Is the Automatic Deduction from my checking account the only way to pay? A: Please contact our office at (888) for more information. Additionally, you can use a savings account as long as you provide a deposit slip imprinted with your name, bank account number and bank routing number. Please note, we are not set up for individual billing and cannot accept a check as payment. Q: When and how will I receive confirmation of my coverage? A: You should receive an from our office within three weeks. Please make sure to check your junk mail folder if you haven t received the . Q: What if I have an emergency before I receive proof of coverage? A: In the event of an emergency situation, you should contact you in the transition period. Group Insurance at (888) Someone will help Q: Why am I not receiving communication from Group Insurance? A: Group Insurance's address ( insurance@agentbenefits.net) may be filtered out by some providers as SPAM. Please ensure to update your address and communication preferences.

3 Full-Time Sales Associates of Meybohm Real Estate Benefits At-A-Glance Dental Insurance The Lincoln DentalConnect PPO Plan: Covers many preventive, basic, and major dental care services Also covers orthodontic treatment for children Features group rates for Meybohm Real Estate Sales Associates Lets you choose any dentist you wish, though you can lower your out-of-pocket costs by selecting a network provider Does not make you and your loved ones wait six months between routine cleanings Calendar (Annual) Deductible In-Network Individual: $50 Family: $150 Waived for: Preventive Out-of-Network Individual: $50 Family: $150 Waived for: Preventive Deductibles are combined for basic and major In-Network services. Deductibles are combined for basic and major Out-of-Network services. Annual Maximum $1,500 $1,500 Annual Maximums are combined for preventive, basic, and major services. Lifetime Orthodontic Max $1,500 $1,500 Orthodontic Coverage is available for dependent children. Waiting Period Visit LincolnFinancial.com/FindADentist You can search by: Location Dentist name or office name Distance you are willing to travel Specialty, language and more There are no benefit waiting periods for any service types Your search will automatically provide up to 100 dentists that most closely match your criteria. If your search does not locate the dentist you prefer, you can nominate one just click the Nominate a Dentist link and complete the online form. 5/1/2019-4/30/2020 $39.11 $88.14 $92.83 $92.83 $ The Lincoln National Life Insurance Company

4 Preventive Services In-Network Out-of-Network Routine oral exams Bitewing X-rays Full-mouth or panoramic X-rays Other dental X-rays (including periapical films) Routine cleanings Fluoride treatments Space maintainers for children Sealants Biopsy and examination of oral tissue (including brush biopsy) Labs & other tests 100% No Deductible 100% No Deductible Basic Services In-Network Out-of-Network Problem focused exams Palliative treatment (including emergency relief of dental pain) Injections of antibiotics and other therapeutic medications Fillings Prefabricated stainless steel and resin crowns Simple extractions Surgical extractions Oral surgery General anesthesia and I.V. sedation Prosthetic repair and recementation services Periodontal maintenance procedures Non-surgical periodontal therapy 80% After Deductible 80% After Deductible Major Services In-Network Out-of-Network Consultations Endodontics (including root canal treatment) Periodontal surgery Bridges Full and partial dentures Denture reline and rebase services Crowns, inlays, onlays and related services Build-ups/post & core TMJ Implants & implant related services Occlusal guard 50% After Deductible 50% After Deductible Orthodontics In-Network Out-of-Network Orthodontic exams X-rays Extractions Study models Appliances 50% 50% DTL-ENRO-BRC001-VA Dental Insurance At-A-Glance 2

5 In-Network/Out-of-Network Dentists In-Network Out-of-Network To find an in-network dentist near you, visit This plan lets you choose any dentist you wish. However, your out-of-pocket costs are likely to be lower when you choose an innetwork dentist. For example, if you need a crown you pay a deductible (if applicable), then 50% of the remaining discounted fee for PPO members. This is known as a PPO contracted fee. you pay a deductible (if applicable), then % of the usual and customary fee, which is the maximum expense covered by the plan. You are responsible for the difference between the usual and customary fee and the dentist s billed charge. DTL-ENRO-BRC001-VA Dental Insurance At-A-Glance 3

6 Dergalis ASSOCIA TES ADMINISTRATIVE USE ONLY EFFECTIVE DATE Dental and Vision Insurance Enrollment Form Page 1 of 3 COMPANY NAME FIRST MI LAST OFFICE LOCATION OCCUPATION Realtor HOME ADDRESS CITY STATE ZIP SS # PHONE HIRE DATE A. PLEASE CHECK ALL COVERAGE(S) YOU ARE APPLYING FOR DENTAL VISION B. PLEASE INDICATE WHO WILL BE INSURED UNDER THE POLICY (CHECK ONLY ONE) Applying for single coverage for myself Applying for myself and dependents listed below C. ENROLLMENT INFORMATION (COMPLETE IF INCLUDING COVERAGE FOR DEPENDENTS) SPOUSE Coverage for: Dental Vision Both FIRST SS# DEPENDENT RELATIONSHIP TO EMPLOYEE MI LAST NAME CHILD 1 Coverage for: Dental Vision Both FIRST MI LAST NAME SS# DEPENDENT RELATIONSHIP TO EMPLOYEE CHILD 2 Coverage for: Dental Vision Both FIRST MI LAST NAME SS# DEPENDENT RELATIONSHIP TO EMPLOYEE CHILD 3 Coverage for: Dental Vision Both FIRST MI LAST NAME SS# DEPENDENT RELATIONSHIP TO EMPLOYEE SIGNATURE REQUIRED I represent that all information supplied in the application is true and correct. Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime. SIGNATURE DATE

7 Automatic Deduction and Notification Agreement Page 2 of 3 PLEASE READ CAREFULLY. BY SIGNING BELOW, YOU AGREE TO HAVING READ AND UNDERSTOOD THE FOLLOWING: I hereby authorize Realty Benefit Services, an affiliate of Dergalis Associates, to access my account for the dental, vision, life, and / or disability insurance premiums. I understand that these deductions will be made periodically and I realize that changes in premiums may result in higher or lower deductions. I further understand that I shall incur additional charges in the event this debit is returned for any reason. In the event that Realty Benefits Services the month, I will be charged $ I understand there is no monthly paper billing from Realty Benefit Services, an affiliate of Dergalis Associates and I cannot pay by check. Notifications I agree to provide signed written notice at least two weeks in advance in the event I wish to cancel, change or amend my current policies. I further agree to indemnify and hold harmless Realty Benefit Services, an affiliate of Dergalis Associates, for charges assessed on my account from my lending institution due to debits for services rendered. I agree to notify Realty Benefit Services, an affiliate of Dergalis Associates, in writing of any changes to my bank account. This notice will be at least two weeks in advance of any scheduled payment debits. (You can fax or your notice to Dergalis Associates at (856) , ATTN: Group Insurance or to insurance@agentbenefits.net.) I understand that these services are being provided solely through arrangements with Realty Benefit Services, an affiliate of Dergalis Associates that I must notify Dergalis Associates in writing if I no longer work as a licensed Realtor or become a notify Dergalis Associates within 30 days of my termination, I realize I may continue to get billed for NO REFUNDS WILL BE PROVIDED FOR MY FAILURE TO NOTIFY DERGALIS ASSOCI ATES OF TERMINATION OR SEPARATION FROM MY REAL ESTATE COMPANY. I understand that any changes to or termination of my coverage will also affect the coverage I have elected for my dependents. By signing, I acknowledge that I have read and accept the terms of the above notification agreement. WERE YOU HELPED BY A DERGALIS REPRESENTATIVE? (please check) YES NO IF YES, WHO: NAME OF INSURED REALTY COMPANY SOCIAL SECURITY # HOME PHONE HOME ADDRESS SIGNATURE of insured OFFICE LOCATION CELL PHONE SIGNATURE REQUIRED CITY STATE ZIP DATE Co-Signature is required if the insured is not listed on the checking account. SIGNATURE of account owner* DATE *Note: Signature should be that of the owner of the checking account whose name appears on the check used for deductions. Revised 8/18/2017

8 Dergalis ASSOCIA TES Page 3 of 3 Attach Voided Check Attach Your Business Card