True Life Destinations 4410 Claiborne Sq E # 334 Hampton, Virginia 23666 ENROLLMENT WORKSHEET Employee Name: Employee Benefits Worksheet This enrollment worksheet outlines the optioins available to you for the 2015-2016 plan year and the corresponding costs. Any elections/waivers that you make will remain in force until the next open enrollment period for that benefit. Please follow the guidelines below to complete your enrollment for this years programs. Instructions: Review the benefit options available to you Complete enrollment forms attached to this sheet (even if you are waiving coverage). a. Blade Benefit Consulting s Enrollment Worksheet b. Anthem enrollment form (new enrollees only) c. United Concorida enrollment form (new enrollees only) Return this form and all enrollment applications to Lisa as soon as possible If you have any questions, please contact Blade Benefit Consulting at 757-544-9130
True Life Destinations 4410 Claiborne Sq E # 334 Hampton, Virginia 23666 Step 1 ENROLLMENT WORKSHEET Employee Name: Please circle the appropriate HEALTH, DENTAL & VISION coverage AMOUNT that you wish to enroll. Circle this box to WAIVE coverage Employee Only Employee + Spouse Employee + Child Employee + Children Family Bi-Weekly Cost Anthem 30/2000/70 United Concordia Dental & Vision WAIVE Enroll Enroll Enroll Enroll Enroll WAIVE $19.54 $39.03 $36.89 $36.89 $60.61 Total
True Life Destinations 4410 Claiborne Sq E # 334 Hampton, Virginia 23666 ENROLLMENT WORKSHEET Employee Name: WAIVER OF HEALTH COVERAGE I delcine coverage for: Declining coverage due to existence of other coverage: Myself and all dependents Spouse's Employer's Plan Individual Plan Spouse Covered by Eligibility Dependent Children COBRA from Prior Employer Other: Tri-Care / Champus I (we) have no other coverage at this time True Life Destinations and I hereby agree that my cash compensation will be reduced by the amount of my required contribution for the benefit option(s) I have elected under True Life Destinations. This shall be effective the first pay period of the new plan year and will continue for each succeeding pay period until this agreement is amended or teminated. Any previous election and compensation reduction agreement under the True Life Destinations Cafeteria Plan relating to the same benefit(s) is hereby revoked. By signing below, you acknowledge you have been given the enrollment booklet and understand the benefit options available. Address: City: State: Zip: Signature: Date:
Employee Enrollment Application For 2 50 Employee Small Groups Virginia Health care plans offered by Anthem Blue Cross and Blue Shield and HealthKeepers, Inc. PPO health care plans are insurance products offered by Anthem Blue Cross and Blue Shield; HMO health care plans are health maintenance organization products offered by HealthKeepers, Inc. You, the employee, must complete this application. You are solely responsible for its accuracy and completeness. To avoid the possibility of delay, answer all questions and be sure to sign and date your application. Application completed for (check company that applies) Anthem Blue Cross and Blue Shield HealthKeepers, Inc. Please complete in blue or black ink only. Section A: Employee Information Last name First name M.I. Social Security no.* (required) Home address Street and PO Box if applicable City City/County State ZIP code Marital status Single Married Domestic Partner Employee email address Primary phone no. Secondary phone no. Employer name Group no. (if known) Employer street address City State ZIP code Employment status Full time Part time Disabled Retired Hire date (MM/DD/YYYY). of hours worked per week Language choice (optional): English Spanish Chinese Korean Other please specify: Section B: Application Type Select one New enrollment Open enrollment COBRA Select qualifying event Left employment Reduction in hours Death Loss of dependent child status Divorce or legal separation Covered employee s entitlement *Anthem is required by the Internal Revenue Service to collect this information. Qualifying event date Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliated HMO HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 37612VAMENABS (1/15) 1032230 37612VAMENABS 2015 Off Exchange Employee App File FR 01 15 R4 1 of 6
Section C: Type of Coverage 1. Medical Coverage Enter network, product and contract code selected: Network select one: Product Contract code KeyCare HealthKeepers HealthKeepers Open Access te for Lumenos Health Savings Account (HSA) enrollees: If you enroll in an Lumenos HSA plan, Anthem will facilitate the opening of a Health Savings Plan in your name, if directed by your employer. Member medical coverage select one: Employee only Employee + Spouse or Domestic Partner Employee + child(ren) Family 2. Dental Coverage I am enrolling in my Employer s dental plan, if any. Member dental coverage select one: Employee only Employee + Spouse or Domestic Partner Employee + child(ren) Family 3. Vision Coverage I am enrolling in my Employer s vision plan, if any. Member vision coverage select one: Employee only Employee + Spouse or Domestic Partner Employee + child(ren) Family 2 of 6
Section D: Coverage Information All fields required. Attach a separate sheet if necessary. Dependent information must be completed for all additional dependents to be covered under this coverage. An eligible dependent may be your spouse or domestic partner, your children, or your spouse s or domestic partner s children (to the end of the calendar month in which they turn age 26 unless they qualify as a disabled person). List all dependents beginning with the eldest. Employee last name First name M.I. Male Female Disabled Birthdate (MM/DD/YYYY) Relationship to applicant Self PCP name PCP ID no. Existing patient Have you used tobacco products 4 or more times per week, on average, in the last 6 months? Are you currently enrolled or willing to enroll in a tobacco cessation wellness program? Spouse or Domestic Partner last name First name M.I. Social Security no.* (required) Male Female Disabled Birthdate (MM/DD/YYYY) Relationship to applicant Spouse Domestic Partner PCP name PCP ID no. Existing patient Has this person used tobacco products 4 or more times per week, on average, in the last 6 months? Has this person currently enrolled or willing to enroll in a tobacco cessation wellness program? Dependent last name First name M.I. Social Security no.* (required) Male Female Disabled Birthdate (MM/DD/YYYY) Relationship to applicant Child Other If other, what is relationship? PCP name PCP ID no. Existing patient Does this dependent have a different address? If yes, please enter: Has this dependent used tobacco products 4 or more times per week, on average, in the last 6 months? Has this dependent currently enrolled or willing to enroll in a tobacco cessation wellness program? Dependent last name First name M.I. Social Security no.* (required) Male Female Disabled Birthdate (MM/DD/YYYY) Relationship to applicant Child Other If other, what is relationship? PCP name PCP ID no. Existing patient Does this dependent have a different address? If yes, please enter: Has this dependent used tobacco products 4 or more times per week, on average, in the last 6 months? Has this dependent currently enrolled or willing to enroll in a tobacco cessation wellness program? Dependent last name First name M.I. Social Security no.* (required) Male Female Disabled Birthdate (MM/DD/YYYY) Relationship to applicant Child Other If other, what is relationship? PCP name PCP ID no. Existing patient Does this dependent have a different address? If yes, please enter: Has this dependent used tobacco products 4 or more times per week, on average, in the last 6 months? Has this dependent currently enrolled or willing to enroll in a tobacco cessation wellness program? *Anthem is required by the Internal Revenue Service to collect this information. 3 of 6
Section E: Other Group Coverage Are you or anyone applying for coverage currently eligible for? If yes, give name: ID no. Part A effective date Part B effective date eligibility reason (check all that apply) Age Disability ESRD: Onset date Part D ID no. Part D Carrier Part D effective date On the day your coverage begins, will you or a family member be covered by? On the day your coverage begins, will you or a family member be covered by other health coverage? If yes to either of these questions, please provide the following: Name of person covered (Last name, first, M.I.) Type (check one) Coverage (check all that apply) Carrier name Carrier phone no. Policy ID no. Dates (if applicable) Individual Group Health Dental Start: End: Individual Group Health Dental Start: End: Individual Group Health Dental Start: End: Individual Group Health Dental Start: End: Individual Group Health Dental Start: End: 4 of 6
Section F: Waiver/Declining Coverage Medical Coverage Medical coverage declined for check all that apply: Myself Spouse or Domestic Partner Dependent(s) Reason for declining coverage check all that apply: Dental Coverage Covered by spouse or domestic partner s group coverage Enrolled in other Insurance Please provide company name and plan: Enrolled in Individual coverage Spouse or domestic partner covered by employer s group medical Coverage /Medicaid/TriCare Other please explain: coverage Dental coverage declined for check all that apply: Myself Spouse or Domestic Partner Dependent(s) I waive coverage for myself and/or my dependents and understand that by waiving coverage, whether entirely or partially paid by my employer, that I waive the right to change this selection unless permitted in the group contract s participation requirements and enrollment restrictions. Anthem Blue Cross and Blue Shield reserves the right to decline any further dental enrollment changes. Vision Coverage Vision coverage declined for check all that apply: Myself Spouse or Domestic Partner Dependent(s) I waive coverage for myself and/or my dependents and understand that by waiving coverage, whether entirely or partially paid by my employer, that I waive the right to change this selection unless permitted in the group contract s participation requirements and enrollment restrictions. Anthem Blue Cross and Blue Shield reserves the right to decline any further vision enrollment changes. Sign here only if you are declining coverage. Signature of applicant Printed name Social Security no. Date (MM/DD/YYYY) X Section G: Terms, Conditions and Authorizations Please read this section carefully before signing the application. Eligible employee: An active employee of the Employer who works the number of hours per week to be eligible for benefits as defined by the Employer and approved by Anthem as of the effective date. Employment must be verifiable from state or federal wage tax reports. An employee, as defined above, who enters into employment after the coverage effective date and who completes the group imposed waiting period for eligibility (if any) and applies for coverage within 31 days. Any other class of persons identified by the Employer, provided that written approval of their eligibility is obtained from the Company(ies); or Employees eligible for continuous coverage under state or federal laws. Eligible employee does not include independent contractors (whose compensation is reported on IRS Form 1099) and directors and officers of the Group Policyholder if they do not work the required number of hours per week described above. Eligible dependent: Employee s spouse, domestic partner, or children younger than age 26, which includes a newborn, natural child, or a child placed with the employee for adoption, a stepchild, domestic partner s child, or any other child for whom the employee has legal guardianship or court-ordered custody. Coverage for children will end on the last day of the month in which the children reach age 26. The age limit of 26 does not apply for the initial enrollment or maintaining enrollment of a child who cannot support himself or herself because of intellectual disability or physical handicap that began prior to the child reaching the age limit. Coverage may be obtained for the child who is beyond the age limit at the initial enrollment if the employee provides proof of handicap and dependence at the time of enrollment. (The employee may be asked to provide a physician s certification of the dependent s condition.) Dependents eligible for continuous coverage under state or federal laws. As an eligible employee, I am requesting coverage for myself and all eligible dependents listed and authorize my employer to deduct any required contributions for this insurance from my earnings. All statements and answers I have given are true and complete. I understand all benefits are subject to conditions stated in the Group Contract and coverage document. 5 of 6
Section G: Terms, Conditions and Authorizations Continued W 9 Certification Language As part of the W 9 Certification required by the Internal Revenue Service (IRS), I certify that the Social Security number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me) and I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding and I am a U.S. citizen or other U.S. person. In signing this application I represent that: I certify that I have read or have had read to me the completed application, and I realize any false statement or misrepresentation in the application may result in loss of coverage. For Health Savings Account enrollees: Except as otherwise provided in any agreement between me and the financial custodian, the custodian of my Health Savings Account (HSA), I understand that my authorization is required before the financial custodian may provide Anthem with information regarding my HSA. I hereby authorize the financial custodian to provide Anthem with information about my HSA, including account number, account balance and information regarding account activity. I also understand that I may provide Anthem with a written request to revoke my authorization at any time. Coverage Option If your employer/group offers HMO coverage which does not permit you to receive the full range of covered services from the provider of your choice, you will also have the option at the time of your initial enrollment and at each renewal to choose a health care plan allowing you to access care from the provider of your choice ( point-of-service plan). This point-of-service plan may be offered by the HMO, Anthem Blue Cross and Blue Shield or by another carrier. Sign Applicant signature Date (MM/DD/YYYY) here X Special Enrollment Rights If you declined enrollment for yourself or your dependent(s) (including a spouse or domestic partner) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependent(s) in this plan if you or your dependent(s) lose eligibility for the other health insurance or group health plan coverage (or if the employer stops contribution towards your coverage or your dependent s other coverage). However, you must request enrollment within 31 days after coverage ends (or after the employer stops contribution toward the other coverage). In addition, if you have a dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependent(s) provided that you request enrollment within 31 days after the marriage, birth, adoption or placement for adoption. I also understand that my dependents and I may enroll under two additional circumstances: Either your or your dependent s Medicaid or Children s Health Insurance Program (CHIP) coverage is terminated as a result of loss of eligibility; or You or your dependent becomes eligible for a subsidy (state premium assistance program). In these cases, you may be able to enroll yourself and your dependents provided that you request enrollment within 60 days of the loss of Medicaid/CHIP or of the eligibility determination. 6 of 6
United Concordia Insurance Company DENTAL ENROLLMENT FORM For New Enrollment, please complete ALL sections of this form. For Enrollment Changes, please complete the applicable Type of Activity change(s) in Section A along with the identification number and employee name in Section B and Section C for dependent changes. SECTION A: GENERAL INFORMATION 1. TYPE OF PROGRAM FFS (Indemnity, Active PPO, Passive PPO - Please Specify) Concordia Access Concordia Choice Concordia Flex Concordia Preferred Concordia Select Other 2. TYPE OF ACTIVITY New Enrollment Cancel Coverage Cancel All Coverage (Employee & All Dependents) Cancel Dependent(s) Only (List dependents to be cancelled) Change (Please Specify) Add Dependent (e.g., spouse, domestic partner, child, etc.) Change Address Reinstate Coverage Change Name Change Group Number COBRA Other Effective Date (mm/dd/yyyy) / / SECTION E: FOR EMPLOYER USE ONLY EMPLOYER INFORMATION Employer Name Group Number Sub Group UCCI Payroll Location SECTION B: EMPLOYEE INFORMATION - Please print clearly to expedite your request. 1. Identification Number ( For example, Social Security Number) 2. Original Employment Date (mm/dd/yyyy) / / 3. Employee Name ( Last, First, Middle Initial ) 4. Date of Birth 5. 6. Provider Number (DHMO Only) 7. Home Address City State Zip Code SECTION C: DEPENDENT INFORMATION Please list the added/cancelled dependents in this section. For more than five dependent children, complete and attach an additional form. If dependent children listed in this section are disabled or full-time students age 19 or over, please see your group administrator for a Dependent Certification Form, which should be completed and returned with the Dental Enrollment Form. 1. Identification Number (For example, Social Security Number) 2. Type 3. Last Name 4. First Name 5. MI 6. 7. Date of Birth Spouse Dependent (A) Dependent (B) Dependent (C) Dependent (D) Other Class Persons of SECTION D: OTHER DENTAL COVERAGE Do you or your dependent(s) have other Group Dental Coverage? If your answer is yes, please complete the following information. Policy Holder Insurance Company P olicy/identification Number E ffective Date ( mm/dd/yyyy) / / Any person who within the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law. Employee Signature Date Employer Signature Phone Number Date VA5000 (07/05) WEB1206