Western Area School Health Benefit Plan Enrollment Directions

Transcription

1 Western Area School Health Plan Enrollment Directions All eligible employees should complete the attached applications for medical and voluntary life. Employees may elect Dental and/or Vision if they are enrolled in the Medical Plan. The Dental and Vision elections can be at a different level than the Medical benefit. For example, an employee may have employee +2 Medical coverage, employee + 3/more Dental coverage and employee only Vision coverage. Remember All eligible employees should complete the voluntary life insurance application. To accept or decline the coverage, the application that is included must be completed. Consociate s Eligibility Department can be contacted at Revised 9/12/2012

2 EMPLOYEE REQUEST FOR GROUP COVERAGE SECTION A: EMPLOYER INFORMATION WESTERN AREA SCHOOL HEALTH BENEFIT PLAN Name of School: School Location Code: (see back for code) Office Use Only: New Enrollment Date of hire _ Effective Date/First Day of Work If you choose to fax the enrollment form to Consociate, please fax it to: (217) Please note: Original must also be mailed to Consociate. SECTION B: EMPLOYEE INFORMATION Last Name: First Name: MI: Marital Status: Single Married Address: City: State: Zip: Home Phone: ( ) Business Phone: ( ) If open enrollment form, did employee provide a letter of certification of previous coverage? No Job Title: Certified Support Staff SECTION C: ELECTION FOR MEDICAL COVERAGE Medical/ Prescription Drug Program: Employee Employee + 1 Employee + 2 Employee + 3/more Deductible Option (choose only one, this applies to employee and dependents) $750 $2,000 Standard $3,000 $5,000 HDHP $3,000 (*See Section H) SECTION D: ELECTION FOR DENTAL COVERAGE **Employee must be enrolled in medical plan to elect dental coverage** Dental Program Employee Employee + 1 Employee + 2 Employee + 3/more SECTION E: ELECTION FOR VISION COVERAGE **Employee must be enrolled in medical plan to elect vision coverage** Vision Program Employee Employee + 1 Employee + 2 Employee + 3/more SECTION F: ELECTION FOR BASIC LIFE INSURANCE Life/AD&D Employee Volume $ Dependent Life (if available through district) SECTION G: LIST EMPLOYEE AND ALL FAMILY MEMBERS TO BE INCLUDED IN YOUR COVERAGE This includes life, medical, dental and/or vision coverage. Name: (Last, First, Middle Initial) Date of Birth Mo./Day/Yr. Sex M/F S. S. # Employee / / - - Spouse / / - - Dependent / / - - Dependent / / - - Dependent / / - - Relationship to Insured Natural Step- Legally Child Child Adopted Other SECTION H: OTHER COVERAGE INFORMATION Do you have any physically or mentally disabled dependents? No If yes, please provide name Are you or your dependents eligible for Medicare? No Are any of the individuals for which you have requested coverage covered by other medical, dental or vision plans? Medical? No Dental? No Vision? No If yes, Name of Insurance Company List Dependents covered by other plan *If you have other insurance coverage, you are not eligible for the $3,000 HDHP. (SEE REVERSE SIDE) Revised 9/12/2012

3 Things You Should Know: Please read carefully 1. After you complete this form, please return it to the insurance representative at your School/Agency s central office. 2. If you are electing any coverage for which you must make premium contributions, you must complete #3, #4 and #5 below; if you are waiving any coverage, you must complete #5 and #6 below. In order to issue ID cards to you, please make sure to complete the employee and dependent enrollment information, INCOMPLETE APPLICATIONS WILL BE RETURNED, DELAYING ELIGIBILITY FOR COVERAGE AND RECEIPT OF YOUR ID CARD. 3. AUTHORIZATION FOR PAYROLL DEDUCTION AND EMPLOYEE ACKNOWLEDGEMENT: I hereby request the insurance indicated for myself and/or my dependents and hereby authorize my employer to make deductions from my earnings of any required contributions to apply toward the premiums for the insurance provided in the policy or group insurance issued to my employer. All information given by me on this form is true and complete. I have read and understand all the information included on this form. I understand that any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. Employee Signature Date 4. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION: I agree to the following terms for myself and my dependents: We authorize, if permitted by law, health care providers, insurers, claims administrators and employers to provide medical, employment and benefit information, including information relating to drug, alcohol, or psychiatric histories and treatment, to the Plan Administrators or their representatives. The Plan Administrators and their representatives may share such information and provide it to other insurers and claims administrators only for the purpose of administrating group coverage and claims for benefits, utilization review, provider peer review and the resolution of grievances. This authorization shall be valid for the term of coverage. I acknowledge that I have obtained a copy of this authorization. I agree that a reproduced copy of this authorization will be as valid as the original. Employee Signature Date 5. Even if you do not elect coverage in the company s benefits plans, you must select a beneficiary for the company paid base life and AD&D benefits. PLEASE PRINT Direct Beneficiary Relationship to you % Contingent Beneficiary Relationship to you % If primary or contingent beneficiary is a minor (under age 18), please provide date of birth. Name of Minor Name of Minor DOB DOB 6. WAIVER OF COVERAGE. If you are declining coverage at this time, please sign the following waiver of coverage: This is to certify that I have been given an opportunity for coverage available to my family members and me through my employer and I have decided to waive my right to coverage at this time. I understand that I may later enroll for medical coverage or any other coverage, if in the presence of a family status change or at open enrollment (pre-existing condition limitations may apply). I have read and understand the following with regard to special enrollments. I understand that it is my responsibility to report to my employer any change in my family (or individual) status. Please indicate the type of coverage you are waiving, indicate the reason and sign below: Medical//Drug Card Dental Vision Reason for waiving coverage: Other Group Medical Coverage Other Group Dental Coverage Other Group Vision Coverage Other: Employee Signature *Please return the completed form to your Insurance Representative.* LOCATION CODES: 001 Abingdon CUSD # Liberty CUSD #2 023 Regional Office of Ed # Astoria CUSD #1 017 Mendon CUSD #4 037 Schuyler-Industry CUSD #5 040 Beardstown CUSD # Mid Illini Educational Coop 025 Southeastern CUSD # Central CUSD #3 039 Midwest Central CUSD # Spoon River Valley CUSD #4 007 Dallas ESD # Payson CUSD #1 028 VIT CUSD #2 009 Fulton Co (Cuba) CUSD #3 019 Pikeland CUSD # Warsaw CUSD # Havana CUSD # Pleasant Hill CUSD #3 038 West Central CUSD # Illini West HSD # Regional Office of Ed #1 029 West Central IL Special Ed Coop 014 LaHarpe CSD # Regional Office of Ed # West Prairie CUSD # Lewistown CUSD # Regional Office of Ed # Western Area Career System Date Revised 9/12/2012

4 ENROLLMENT FORM FOR GROUP INSURANCE Underwritten by: Lincoln National Life Insurance Company A Stock Company Home Office Location: Fort Wayne, Indiana Group Insurance Service Office: 8801 Indian Hills Drive, Omaha NE Phone: (800) Fax: (877) Group ID: WESAS Employee Information (Complete for ALL Enrollments) Employer Name/Company Name Trustees of the Western Area Schools Health Plan Group Policy #: Billing Division or Location: County Employer ZIP State Employee First Name / Middle Initial / Last Name Social Security Number Date of Birth Street Address / City / State / Zip Gender: Marital Status: Home Phone ( ) Spouse First Name / Middle Initial / Last Name Spouse Social Security Number Work Phone ( ) Employee Work Information (Complete for ALL Enrollments) Average Work Week Hours: Occupation: $ Earnings: Full-Time Employment Date: Rehire Date: Product Selection (Complete for ALL Enrollments) Voluntary Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. Type of Coverage Voluntary Employee Life Only Voluntary Employee Life + AD&D Evidence of Insurability Required for Coverage Amounts Over $100,000 Selecting yes authorizes my employer to payroll deduct premium(s) Employees must elect coverage in order to elect spouse and/or dependent coverage Amount of Coverage $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 OTHER $ Life+AD&D $ Premium $ Life Only Voluntary Spouse Life Only Voluntary Spouse Life + AD&D Evidence of Insurability Required for Coverage Amounts Over $30,000 Voluntary Dependent Child Spouse coverage selection may not exceed 50% of the Employee amount selected $10,000 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 OTHER $ $ $ $2.00 *By selecting no, application for coverage at a later date may require further medical information and/or a physical exam, which will be at my own expense. STEPS 0706 Please See Reverse for Beneficiary and Signature. IL

5 Beneficiary Information (Complete ONLY for Life or AD&D Enrollments) Primary Beneficiary's Last Name First MI Relationship of Social Security Number Beneficiary Street Address City State Zip Contingent Beneficiary's Last Name First MI Relationship of Social Security Number Beneficiary Street Address City State Zip Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper. NOTE: A PERSON COMMITS INSURANCE FRAUD, IF HE OR SHE SUBMITS AN APPLICATION OR CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH INTENT TO DEFRAUD (OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD) AN INSURANCE COMPANY. The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not actively at work, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. Employee Full Name: Employee Signature: Date: STEPS 01/05 IL

6 Trustees of The Western Area Schools Health Plan Employee Life Premium for Sample Amounts Spouse premiums will be based on the Employee s age $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 <30 $.60 $1.20 $1.80 $2.40 $3.00 $3.60 $4.20 $4.80 $5.40 $ $.60 $1.20 $1.80 $2.40 $3.00 $3.60 $4.20 $4.80 $5.40 $ $.90 $1.80 $2.70 $3.60 $4.50 $5.40 $6.30 $7.20 $8.10 $ $1.40 $2.80 $4.20 $5.60 $7.00 $8.40 $9.80 $11.20 $12.60 $ $2.40 $4.80 $7.20 $9.60 $12.00 $14.40 $16.80 $19.20 $21.60 $ $3.50 $7.00 $10.50 $14.00 $17.50 $21.00 $24.50 $28.00 $31.50 $ $5.20 $10.40 $15.60 $20.80 $26.00 $31.20 $36.40 $41.60 $46.80 $ $8.60 $17.20 $25.80 $34.40 $43.00 $51.60 $60.20 $68.80 $77.40 $ $6,500 $13,000 $19,500 $26,000 $32,500 $39,000 $45,500 $52,000 $58,500 $65, ** $10.14 $20.28 $30.42 $40.56 $50.70 $60.84 $70.98 $81.12 $91.26 $ $4,000 $8,000 $12,000 $16,000 $20,000 N/A N/A N/A N/A N/A 70-74** $8.80 $17.60 $26.40 $35.20 $44.00 N/A N/A N/A N/A N/A $2,500 $5,000 $7,500 $10,000 $12,500 N/A N/A N/A N/A N/A 75-99** $11.88 $23.75 $35.63 $47.50 $59.38 N/A N/A N/A N/A N/A Spouse Life Premium for Sample Amounts Spouse premiums will be based on the Employee s age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 <30 $.30 $.60 $.90 $1.20 $1.50 $1.80 $2.10 $2.40 $2.70 $ $.30 $.60 $.90 $1.20 $1.50 $1.80 $2.10 $2.40 $2.70 $ $.45 $.90 $1.35 $1.80 $2.25 $2.70 $3.15 $3.60 $4.05 $ $.70 $1.40 $2.10 $2.80 $3.50 $4.20 $4.90 $5.60 $6.30 $ $1.20 $2.40 $3.60 $4.80 $6.00 $7.20 $8.40 $9.60 $10.80 $ $1.75 $3.50 $5.25 $7.00 $8.75 $10.50 $12.25 $14.00 $15.75 $ $2.60 $5.20 $7.80 $10.40 $13.00 $15.60 $18.20 $20.80 $23.40 $ $4.30 $8.60 $12.90 $17.20 $21.50 $25.80 $30.10 $34.40 $38.70 $ $3,250 $6,500 $9,750 $13,000 $16,250 $19,500 $22,750 $26,000 $29,250 $32, ** $5.07 $10.14 $15.21 $20.28 $25.35 $30.42 $35.49 $40.56 $45.63 $ N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A EXAMPLE: Use this formula to calculate premium for benefit amounts not shown above. Age in 's Cost Example X 120 = $7.20 Yours X = Dependent Children Premium = $2.00 for $10, coverage on all of your dependent children Rates change on policy anniversary based on your attained age. If electing amounts over the Guarantee Issue for your age, you must complete an Evidence of Insurability form. **The coverage amounts and rates illustrated on ages reflect the reduction in benefits. STEPS 01/05 IL

7 Trustees of The Western Area Schools Health Plan Employee Life and AD&D Premium for Sample Amounts Spouse premiums will be based on the Employee s age $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 <30 $.85 $1.70 $2.55 $3.40 $4.25 $5.10 $5.95 $6.80 $7.65 $ $.85 $1.70 $2.55 $3.40 $4.25 $5.10 $5.95 $6.80 $7.65 $ $1.15 $2.30 $3.45 $4.60 $5.75 $6.90 $8.05 $9.20 $10.35 $ $1.65 $3.30 $4.95 $6.60 $8.25 $9.90 $11.55 $13.20 $14.85 $ $2.65 $5.30 $7.95 $10.60 $13.25 $15.90 $18.55 $21.20 $23.85 $ $3.75 $7.50 $11.25 $15.00 $18.75 $22.50 $26.25 $30.00 $33.75 $ $5.45 $10.90 $16.35 $21.80 $27.25 $32.70 $38.15 $43.60 $49.05 $ $8.85 $17.70 $26.55 $35.40 $44.25 $53.10 $61.95 $70.80 $79.65 $ $6,500 $13,000 $19,500 $26,000 $32,500 $39,000 $45,500 $52,000 $58,500 $65, ** $10.30 $20.61 $30.91 $41.21 $51.51 $61.82 $72.12 $82.42 $92.72 $ $4,000 $8,000 $12,000 $16,000 $20,000 N/A N/A N/A N/A N/A 70-74** $8.90 $17.80 $26.70 $35.60 $44.50 N/A N/A N/A N/A N/A $2,500 $5,000 $7,500 $10,000 $12,500 N/A N/A N/A N/A N/A 75-99** $11.94 $23.88 $35.82 $47.75 $59.69 N/A N/A N/A N/A N/A Spouse Life and AD&D Premium for Sample Amounts Spouse premiums will be based on the Employee's age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 <30 $.43 $.85 $1.28 $1.70 $2.13 $2.55 $2.98 $3.40 $3.83 $ $.43 $.85 $1.28 $1.70 $2.13 $2.55 $2.98 $3.40 $3.83 $ $.58 $1.15 $1.73 $2.30 $2.88 $3.45 $4.03 $4.60 $5.18 $ $.83 $1.65 $2.48 $3.30 $4.13 $4.95 $5.78 $6.60 $7.43 $ $1.33 $2.65 $3.98 $5.30 $6.63 $7.95 $9.28 $10.60 $11.93 $ $1.88 $3.75 $5.63 $7.50 $9.38 $11.25 $13.13 $15.00 $16.88 $ $2.73 $5.45 $8.18 $10.90 $13.63 $16.35 $19.08 $21.80 $24.53 $ $4.43 $8.85 $13.28 $17.70 $22.13 $26.55 $30.98 $35.40 $39.83 $ $3,250 $6,500 $9,750 $13,000 $16,250 $19,500 $22,750 $26,000 $29,250 $32, ** $5.15 $10.30 $15.45 $20.61 $25.76 $30.91 $36.06 $41.21 $46.36 $ N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A EXAMPLE: Use this formula to calculate premium for benefit amounts not shown above. Age in 's Cost Example X 120 = $10.20 Yours X = Dependent Children Premium = $2.00 for $10, coverage on all of your dependent children Rates change on policy anniversary based on your attained age. If electing amounts over the Guarantee Issue for your age, you must complete an Evidence of Insurability form. **The coverage amounts and rates illustrated on ages reflect the reduction in benefits. STEPS 01/05 IL