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INSTRUCTIONS FOR COMPLETING – SEE PAGE 3 Benefits Enrollment/Change Form1. (Check off Appropriate Box) FORMCHECKBOX New Employee FORMCHECKBOX Annual Open Enrollment Effective Date: FORMTEXT ?????Division: FORMCHECKBOX US Insurance FORMCHECKBOX Reinsurance FORMCHECKBOX Life Status Change FORMDROPDOWN (Attach appropriate Documentation)2. Employee Information (Please Print) Name (Last, First, Middle Initial) FORMTEXT ?????Date of Hire FORMTEXT ????? FORMCHECKBOX Male FORMCHECKBOX FemaleAddress (Street) (City) (State) (Zip) FORMTEXT ????? FORMCHECKBOX Married FORMCHECKBOX Single FORMCHECKBOX Domestic PartnerSocial Security Number FORMTEXT ?????Date of Birth FORMTEXT ?????Work Location FORMDROPDOWN 3. Medical/Dental/Vision Coverage (Must select one)Medical Plan Coverage Level of Medical Coverage Dental Plan CoverageLevel of Dental Coverage FORMCHECKBOX PPO (BC/BS) FORMCHECKBOX Employee Only FORMCHECKBOX Enroll FORMCHECKBOX Employee Only FORMCHECKBOX No Coverage FORMCHECKBOX Employee + 1 FORMCHECKBOX No Coverage FORMCHECKBOX Employee + Spouse FORMCHECKBOX Employee + Family FORMCHECKBOX Employee + Child(ren)Vision Coverage FORMCHECKBOX Enroll FORMCHECKBOX No Coverage Level of Vision Coverage FORMCHECKBOX Employee Only FORMCHECKBOX Employee + 1 FORMCHECKBOX Employee + Child(ren) FORMCHECKBOX Employee + Family FORMCHECKBOX Employee + Family FORMCHECKBOX No Coverage Medical/Dental/Vision (Sign Waiver)Waiver of Coverage (sign only if you are waiving out of all benefits)Employee Signature:(Waiver Only) ____________________________________________________ Date Signed____________________I elect not to participate in the medical/dental or vision coverage available through my employment with Aspen. I understand that my waiver means that I will generally not be able to elect to participate in the benefit coverage for the remainder of this year, but I may elect to participate in the benefit coverage during the next annual enrollment period.? There are limited circumstances that will permit me to elect benefit coverage for the remainder of the year, including (i)?if I acquire a new dependent as a result of marriage, birth, adoption, or placement for adoption,?or?(ii) if I lose?other health coverage I have at the time of my waiver, if the reason I am declining my medical coverage through Aspen is because of this other coverage.? To elect medical coverage for the remainder of the year if you experience any event that allows a mid-year enrollment, you must request enrollment within 30 days of the event.? For more information about mid-year events that will allow you to request enrollment, see the Summary Plan Description for the benefit plan, or contact Lizet Cardinoza at 646-289-4902/ lizet.cardinoza@aspen.co Dependent Information (List only eligible dependents) (List additional dependents on a separate sheet of paper and attach to this form) 4. Proof of dependency is required and must be provided to add a dependent to an Aspen benefits plan (ie. birth certificate, marriage certificate, SS card). Proof of disabled status is required for medical, dental and vision coverage for dependents over age 26.Dependent Name(Last, First, Middle Initial)Social Security #RelationshipSex(M/F)Birth DateType of CoverageCheck all that apply FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????/ FORMTEXT ????/ FORMTEXT ???? FORMCHECKBOX Med FORMCHECKBOX Vis FORMCHECKBOX Den FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????/ FORMTEXT ????/ FORMTEXT ???? FORMCHECKBOX Med FORMCHECKBOX Vis FORMCHECKBOX Den Dependent Name(Last, First, Middle Initial)Social Security #RelationshipSex(M/F)Birth DateType of CoverageCheck all that apply FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????/ FORMTEXT ????/ FORMTEXT ???? FORMCHECKBOX Med FORMCHECKBOX Vis FORMCHECKBOX Den FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????/ FORMTEXT ????/ FORMTEXT ???? FORMCHECKBOX Med FORMCHECKBOX Vis FORMCHECKBOX Den FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????/ FORMTEXT ????/ FORMTEXT ???? FORMCHECKBOX Med FORMCHECKBOX Vis FORMCHECKBOX Den 5. Flexible Spending AccountsHealth Care FSA FORMCHECKBOX Enroll AMOUNT (annual): $ FORMTEXT ????? FORMCHECKBOX Do Not EnrollAnnual Maximum $5000Dependent Care FSA FORMCHECKBOX Enroll AMOUNT (annual): $ FORMTEXT ????? FORMCHECKBOX Do Not EnrollAnnual Maximum $50006. Parking and Transit (Commuter Benefits Program)Pre-Tax Transit FORMCHECKBOX Enroll AMOUNT (monthly): $ FORMTEXT ????? FORMCHECKBOX Do Not EnrollMonthly Maximum ($125.00)Pre-Tax Parking FORMCHECKBOX Enroll AMOUNT (monthly): $ FORMTEXT ????? FORMCHECKBOX Do Not EnrollMonthly Maximum ($240.00)I hereby request coverage under the group programs specified and understand that the coverage provided will be subject to the terms and conditions of the group insurance policy. I hereby authorize my employer to make pre-tax deductions in my salary, as needed, to pay for the appropriate coverage(s) requested. Increases in my coverage may require proof of insurability. Employee Signature:_______________________________________________________________ Date Signed_______________________ INSTRUCTIONSPlease complete this form carefully. Your group insurance coverage with Aspen is dependent on completion of this form and its return to Human Resources within 30 days of eligibility or status change. Section 1. Check appropriate box. Once you enroll, you can only make a change in coverage (increasing coverage, decreasing coverage, enrolling in coverage or dropping coverage), during the annual enrollment or if you have a “Change in Family Status.” Section 2. Employee Information Enter information requested. Section 3. Medical/Dental/Vision Select the type of Plan Coverage and place an X in the appropriate box for medical, dental and vision. If no benefit coverage is desired you must still place an X in the “No Coverage” box and sign the Waiver of Coverage. Section 4. Dependent Information If Employee + Dependents were indicated for medical, dental and/or vision coverage, enter only the dependents to be covered. Please list the full names of the eligible dependents (refer to the appropriate Summary Plan Description for definition of eligible dependents), Social Security Number (required for spouse) and when available, for other dependents, (IRS Code indicates all children age 5 and over should have a Social Security Number). Indicate relationship: spouse, son, daughter, stepson, stepdaughter, etc., and gender, plus "Date of Birth" (month/day/year.) After completing all of the above, read the final paragraph above the signature box, sign and date the form. You will also need to complete a Beneficiary Designation form. NO SCRATCH-OUTS OR CHANGES ACCEPTED - IF WRONG CHOICE IS MARKED, PREPARE A NEW FORM ................
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