CITY OF DESTIN - Gulfport, Florida



CITY OF GULFPORT

Benefits Election Form (Becomes Effective – October 1, 2016)

EMPLOYEE NAME: DEPARTMENT:

INSTRUCTIONS: PLEASE SELECT ONE OPTION FROM EACH CATEGORY. IF THERE ARE NO CHANGES TO YOUR CURRENT PLAN SELECTIONS, PLEASE CHECK OFF “NO” UNDER THE CHANGE IN PLAN BENEFIT QUESTION. IF YOU ARE MAKING A CHANGE, PLEASE SELECT THE NEW PLAN BENEFIT AND CHECK OFF “YES” UNDER THE CHANGE IN BENEFIT QUESTION. PLEASE REMEMBER TO ATTACH THE PROPER CHANGE FORM(S) FOR ANY CHANGE(S) THAT YOU ARE MAKING TO YOUR PLAN STRUCTURES. ALL FORMS MUST BE RECEIVED IN THE HUMAN RESOURCES OFFICE BY TUESDAY, AUGUST 23, 2016.

ALL PRE-PAID INSURANCE PLAN DEDUCTIONS WILL COMMENCE ON THE FIRST PAY PERIOD OF SEPTEMBER 2016.

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MEDICAL INSURANCE – BASE PLAN – Blue Options 03559 - Initial & Circle Coverage Election:

(Initial) Coverage Per Pay Period

Authorized: Employee/Dependents Emp bi-wkly cost

Employee Only No Charge CHANGE IN MEDICAL PLAN FROM

Employee & Spouse $ 280.27 CURRENT YEAR?

Employee & Child(ren) $ 174.72

Employee & Family $ 411.02 YES_______ NO_______

MEDICAL INSURANCE – PPO – Blue Choice 0727 - Initial & Circle Coverage Election:

(Initial) Coverage Per Pay Period

Authorized: Employee/Dependents Emp bi-wkly cost

Employee Only $ 24.67

Employee & Spouse $ 343.49

Employee & Child(ren) $ 226.78

Employee & Family $ 488.14

MEDICAL INSURANCE – PPO – Blue Options 05901 - Initial & Circle Coverage Election:

(Initial) Coverage Per Pay Period

Authorized: Employee/Dependents Emp bi-wkly cost

Employee Only No Charge

Employee & Spouse $ 163.50

Employee & Child(ren) $ 77.17

Employee & Family $ 270.47

I AM WAIVING MEDICAL COVERAGE ______________ (PLEASE INITIAL).

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DENTAL INSURANCE – LOW PPO PLAN – FLORIDA COMBINED LIFE – Initial & Circle Coverage Type:

(Initial) Coverage Per Pay Period

Authorized: Employee/Dependents Emp bi-wkly cost

Employee Only $ 13.32 CHANGE IN DENTAL PLAN?

Employee + One Dep $ 27.97

Employee + Two Dep $ 46.61 YES_______ NO_______

DENTAL INSURANCE – HIGH PPO PLAN – FLORIDA COMBINED LIFE – Initial & Circle Coverage Type:

(Initial) Coverage Per Pay Period

Authorized: Employee/Dependents Emp bi-wkly cost

Employee Only $ 16.65

Employee + One Dep $ 34.96

Employee + Two Dep $ 58.26

I AM WAIVING DENTAL COVERAGE ______________ (PLEASE INITIAL).

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VISION INSURANCE – VSP – Initial & Circle Coverage Type:

(Initial) Coverage Per Pay Period

Authorized: Employee/Dependents Emp bi-wkly cost

Employee Only $ 3.03 CHANGE IN VISION PLAN?

Employee & Spouse $ 6.05

Employee & Child(ren) $ 5.47 YES ______ NO _______

Employee & Family $ 10.33

I AM WAIVING VISION COVERAGE ______________ (PLEASE INITIAL).

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LINCOLN FINANCIAL GROUP – VOLUNTARY LIFE POLICY

Are you making a change to your current policy? YES ______ NO________ (Please provide proper form)

Are you adding this coverage to your benefits? YES ______ NO________ (Please provide proper form)

Are you updating your beneficiary information? YES ______ NO________ (Please provide proper form)

I AM WAIVING VOLUNTARY LIFE COVERAGE ______________ (PLEASE INITIAL).

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AFLAC – SUPPLEMENTAL INSURANCE COVERAGE

Are you making a change to your current policy? YES ______ NO________ (Please provide proper form)

Are you adding this coverage to your benefits? YES ______ NO________ (Please provide proper form)

I AM WAIVING AFLAC SUPPLENTAL INSURANCE COVERAGE ______________ (PLEASE INITIAL).

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COLONIAL – SUPPLEMENTAL INSURANCE COVERAGE

Are you making a change to your current policy? YES ______ NO________ (Please provide proper form)

Are you adding this coverage to your benefits? YES ______ NO________ (Please provide proper form)

I AM WAIVING COLONIAL SUPPLENTAL INSURANCE COVERAGE ______________ (PLEASE INITIAL).

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NATIONWIDE RETIREMENT SOLUTIONS:

*Are you interested in meeting with a company representative? YES ______ NO _______

ICMA RETIREMENT PLAN SPECIALIST:

*Are you interested in meeting with a company representative? YES ______ NO _______

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I UNDERSTAND THAT THIS FORM (ALONG WITH THE PROPER CHANGE REQUEST FORM

FROM THE PROVIDER) MUST BE SUBMITTED TO H.R. BY TUESDAY, AUGUST 23, 2016, FOR THE CHANGE TO BE PROCESSED FOR THIS OPEN ENROLLMENT PERIOD, WHICH BECOMES EFFECTIVE OCTOBER 1, 2016.

EMPLOYEE NAME: SIGNATURE:

DATE SUBMITTED TO H.R.: ______________________________________

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