CARE USA – International



2010 US Add/Delete Enrollment Change Form

[pic]

Please type or print in ink:

|Your Name: Last First M.I. |

| |

|Social Security No.* |Date of Birth |Male |Single |Employee ID Number |

| |MM/DD/YYYY |Female |Married | |

|Street Address |

|City |State |Zip Code |

□ Add a dependent(s)

□ Delete a dependent(s)

Please check the reason for the change in coverage and indicate the effective date.

□ Marriage on ________________________________

□ Divorce on _________________________________

□ Birth or adoption of a child on ___________________________

□ Death of a spouse on ________________________

□ Termination or commencement of spouse’s employment on ______________________

□ Change in your or your spouse’s employment status (part-time to full-time or full-time to part-time) on _________________

□ Other (please explain) ________________________________________________________________________________

Please check the appropriate boxes below to reflect your new benefit selections:

Medical Dental Vision Vision Plus

Member Only ( $79.46/mo ( $ 5.44/mo ($1.76 /mo ( $ 5.80/mo

Member+One ( $181.25/mo ( $54.27/mo ($3.26 /mo ( $10.92/mo

Member+Family ( $250.57/mo ( $96.44/mo ($4.75/ mo ( $16.00/mo

( Drop Coverage ( Drop Coverage ( Drop Coverage ( Drop Coverage

( No Change ( No Change ( No Change ( No Change

Supplemental Life* Dependent Life Supplemental Long-Term Disability**

(1X (2X (3X (4X (5X ( Add $6.60/mo ( Yes $__________

( Waive ( Waive

*Supplemental Life coverage is based upon employee’s salary and requires approval from insurance carrier for additional coverage.

**See “Instructions” page to determine the coverage cost and approval process.

Flexible Spending Accounts

Medical $ / year Calendar Year Max = $2,500 Dependent Care $ / year Calendar Year Max = $5,000

( Drop Account ( Drop Account

If you enroll at the beginning of the year, you will have 24 pay period deductions. If you enroll anytime thereafter, your elected yearly contribution amount will be divided evenly by the remaining benefit deduction pay periods.

Dependent Information

If you are adding or dropping a dependent(s), please list below:

| | | | | | | | |

|Last Name |First Name |M.I. |Date of Birth |Relationship*** |Social Security No. |Gender |Add or Drop |

| | | |MM/DD/YYYY | | |M/F | |

| | | | | | | | |

| | | | | | | | |

*** Please indicate “SP” for Spouse, “C” for Child, “DC” for Disabled Child and “DP” for Domestic Partner. “Child” refers to unmarried dependent children up to age 19, or up to age 25 if a full time student. Proof of enrollment (example: registrar letter showing dates of enrollment) will be required to verify current full-time student enrollment. “Disabled Child” refers to a child of any age who is disabled according to SSA guidelines.

If you need to enroll or make changes to your dependent care or healthcare spending accounts, please contact the benefits unit for other forms if needed (direct deposit, eligible expenses, etc…).

Signature and Authorization

I confirm that I have made the above benefit selections consistent with my change in job/family status. I understand that these changes must be requested within thirty-one (31) days of the qualifying event. I hereby authorize the deduction from my earnings of any required contributions toward the cost of such insurance. I also authorize the release of the respective insurance company or its representatives any medical information or insurance information deemed necessary to process a benefits claim on my dependents or me. I authorize any educational institution to furnish my employer or insurance carrier with information necessary to establish student eligibility. I certify that the information provided on this form is accurate and complete.

Employee’s Signature (do not print) Date

-----------------------

[pic]

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download