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

Transcription

1 Dergalis ASSOCIATES Group Enrollment Processing In order to ensure proper processing 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) ake sure you have signed and completed the application(s) in their entirety. Check them for any errors or missing information. 3) Review, complete and sign the Automatic Deduction Agreement form. 4) ake 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) ax your application with the Automatic Deduction Agreement and the voided check to the Insurance Department fax number shown below. We UST 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. Claire Rightler Benefits Administrator P: (888) , toll free P: (856) , direct : (856) E: claire@agentbenefits.net ax all finished paperwork to: ATTN: Claire (856)

2 Q: ust I take all of the benefits? A: No, each benefit can be purchased individually. requently Asked Questions Q: Will I get another opportunity to enroll if I decline to take coverage now? A: Once a year, the Group and 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 and. If I lose that coverage, could I participate in your program? A: Yes, you will have the opportunity to enroll in the or plan within 30 days of a qualifying life event such as birth, death, divorce or loss of coverage. or 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 Claire Rightler at (888) Claire will help you in the transition period. Q: Why am I not receiving communication from Claire? A: Claire s address (claire@agentbenefits.net) may be filtered out by some providers as SPA. Please ensure to update your address and communication preferences.

3 Designer Plan Healthy eyes and clear vision are an important part of your overall health and quality of life. Your vision plan helps you care for your eyes while saving you money by offering: Paid-in-full eye examinations and eyeglasses! rame Collection: Your plan includes a selection of designer, name brand frames that are completely covered in full. /1 IN-NETWORK BENEITS Eye Examination Eyeglasses Spectacle Lenses rames Contact Lenses Every 12 months, Covered in full Every 12 months, Covered in full or standard single-vision, lined bifocal, or trifocal lenses Every 12 months, Covered in full Any asion frame from s Collection /1 value up to $100) OR $60 retail allowance toward any frame from provider. One-year eyeglass breakage warranty included on plan eyewear at no additional cost! How to locate a Network Provider... Log on to Davisvision.com. Click on ember/open Enrollment, then enter Client Code Click ind a Provider to locate a provider near you including: Contact Lenses (in lieu of eyeglasses) Every 12 months $75 retail allowance toward provider supplied contact lenses. ADDITIONAL DISCOUNTED LENS OPTIONS & COATINGS OST POPULAR OPTIONS Savings based on in-network usage and average retail values. Without With Scratch Resistant Coating $25 Polyycarbonate Lenses $66 $83 /2 -$35 $40 Standard Progressives (no-line bifocal) $198 $65 Plastic Photosensitive lenses /3 $110 $70 Service Without See the savings! With or more Details... Contact Claire Rightler, Your Benefit Administrator. P: (888) : (856) E: claire@agentbenefits.net Eye Examination $103 Lenses Bifocals $116 Scratch-Resistant Coating $25 Transitions /3 $110 rame $160 Total $514 $70 $70 Savings up to: $444 1/ The Collection is available at most participating independent provider locations. Collection is subject to change. 2/ or dependent children, monocular patients and patients with prescriptions of 6.00 diopters or greater. 3/ Transitions is a registered trademark of Transitions Optical Inc. has made every effort to correctly summarize your vision plan features. In the event of a conlict between this information and your organization s contract with, the terms of the contract or insurance policy will prevail. ember Contribution rates good through April 30, 2019 onthly Annually ember $7.89 $94.68 ember plus Spouse ember plus Child ember plus Children ember plus amily $15.77 $ $15.77 $ $23.66 $ $23.66 $ OE /11/15

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5 Dergalis ASSOCIATES ADINISTRATIVE USE ONLY EECTIVE DATE Page 1 of 3 and Insurance Enrollment orm COPANY NAE CHECK ONE HOWARD HANNA (OH, I, PA) HOWARD HANNA- VA HOWARD HANNA- ROCHESTER HOWARD HANNA- NY NAE OICE LOCATION HOE ADDRESS CITY STATE ZIP SS # EAIL PHONE HIRE DATE A. PLEASE CHECK ALL COVERAGE(S) YOU ARE APPLYING OR DENTAL ( Basic Comprehensive) DAVIS 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. ENROLLENT INORATION (COPLETE I INCLUDING COVERAGE OR DEPENDENTS) SPOUSE NAE CHILD 1 NAE CHILD 2 NAE CHILD 3 NAE 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

6 Automatic Deduction and Notification Agreement Page 2 of 3 PLEASE READ CAREULLY. BY SIGNING BELOW, YOU AGREE TO HAVING READ AND UNDERSTOOD THE OLLOWING: 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: Claire Rightler or to claire@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 REUNDS WILL BE PROVIDED OR Y AILURE TO NOTIY DERGALIS ASSOCIATES O TERINATION OR SEPARATION RO Y REAL ESTATE COPANY. 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. SIGNATURE of insured SIGNATURE REQUIRED DATE WERE YOU HELPED BY A DERGALIS REPRESENTATIVE? (please check) YES NO I YES, WHO: NAE O INSURED REALTY COPANY SOCIAL SECURITY # HOE PHONE HOE ADDRESS SIGNATURE of account owner* OICE LOCATION EAIL CELL PHONE CITY STATE ZIP SIGNATURE REQUIRED DATE *Note: Signature should be that of the owner of the checking account whose name appears on the check used for deductions. Revised 4/04/2016

7 Dergalis ASSOCIATES Page 3 of 3 Attach Voided Check Attach Your Business Card