VOLUNTARY BENEFIT PLAN ENROLLMENT FORM
HEALTH CARE PLAN FOR RETIREES OF
CHILDREN’S HOME SOCIETY OF FLORIDA
2011-2012 ENROLLMENT FORM
Any elections left blank or incomplete will be considered “waived.”
| |Gender: M F |Benefits Department Use Only |
|Name: | | |
| | Form Received: ____/____/____ |
|Street Address: | |
| | Initials: ____________________ |
|City, State, Zip: | |
| | | |
|Social Security Number: |Phone Number: |Effective Date: ______________ |
| |Date of Retirement: | |
|Date of Birth: | | |
|MEDICAL PLAN OPTIONS |
| Aetna HRA HNOption Plan | Retiree Only WAIVE MEDICAL COVERAGE |
|Aetna HRA HNOnly Plan |Retiree and Spouse |
|Panama City, Pensacola and Indian River County: |Retiree and Child(ren) |
|Aetna HRA PPO Plan |Retiree and Family |
|Tallahassee Only: | |
|Capital Health Plan Capital Selection Plan | |
|DENTAL PLAN OPTIONS |
| Aetna Low Option PPO Plan | Retiree Only WAIVE DENTAL COVERAGE |
|Aetna High Option and Passive PPO Plan |Retiree and One Dependent |
| |Retiree and Family |
|VISION PLAN |
| Advantica EyeCare Select Plus 150 Plan | Retiree Only WAIVE VISION COVERAGE |
| |Retiree and Family |
|DEPENDENT INFORMATION |
|You must complete this information if you are electing dependent coverage. If you need additional spaces, please attach another enrollment form. The eligibility of |
|all dependents must be verified. Please contact your local HR Department for information on dependent eligibility verification. |
|Full Name |Relationship |Gender |SSN |Date of Birth |Medical |Dental |Vision |
| | | |(Required) |(Required) | | | |
| |Spouse | M F | | | Yes | Yes | Yes |
| | | | | |No |No |No |
| |Child | M F | | | Yes | Yes | Yes |
| | | | | |No |No |No |
| |Child | M F | | | Yes | Yes | Yes |
| | | | | |No |No |No |
|AUTHORIZATION |
|I understand my benefit choices. I understand and agree that any elections left blank or incomplete will be considered “waived.” These elections replace any previous |
|elections and will terminate the earlier of (1) the last day of the month in which I make my final premium payment, or (2) the last day of the month when I am no |
|longer eligible to participate in the program due to my becoming eligible for Medicare. |
| |
| |
|Signature Date |
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