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.
[pic]
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).
[pic]
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).
[pic]
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).
[pic]
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).
[pic]
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).
==============================================================================================
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).
===============================================================================================
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 _______
===============================================================================================
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.: ______________________________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- city of university city mo
- city of kansas city kansas
- city of pensacola florida jobs
- city of u city mo
- city of kansas city mo
- city of university city missouri
- city of kansas city ks
- city of gadsden city council
- city of irving city hall
- city of worthington city council
- city of missouri city permits
- city of university city permits