Fillable 2018 2019 Open Enrollment Worksheet 04182018

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2018 2019 Open Enrollment Worksheet 04182018

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Wilkes University
Flexible Benefits Worksheet
June 1, 2018 to December 31, 2018
NAME:
WIN:
SSN:
Please Check
GENDER
SOCIAL SECURITY NUMBER COVERAGE:
Self M D V
Spouse M D V
Child M D V
Child M D V
Child M D V
Child M D V
Child M D V
TIER
Change to:
Plan: Plan:
Tier: Tier:
TIER
2) Employee + 1
Change to:
Plan: Plan:
Tier: Tier:
$21.04
$30.83
Please provide the following information for all persons to be covered under the medical (M) , dental (D)
and vision (V) plans.
NAME
DATE OF BIRTH
MEDICAL INSURANCE PLANS
1) Single
B) Blue Care HMO
C) PPO Blue $1000
$53.33
$67.03
5) Family
A) PPO Blue
$400 Deductible
$225.55
$262.04
$305.06
$335.05
2) Parent & Child
3) Parent & Children
4) Employee & Spouse
$201.84
$234.51
$273.01
$299.84
1) Single
$9.97
$14.61
Current Coverage:
DENTAL INSURANCE PLANS
A) United Concordia
Basic
B) United
Concordia
Enhanced
NO CHANGES:
3) Family
$26.76
$39.12
Current Coverage:
NO CHANGES:
(Short Plan Year)
EFFECTIVE DATE:
Check to Decline
Medical:
Check to Decline
Dental:
Must provide proof of other
medical coverage to receive
$50 per pay
6/1/2018
TIER
Change to:
Tier: Tier:
Amount Rate Amount Rate Month Day
Amount Rate Amount Rate Month Day
Per Plan
Year
Per Pay
Per Plan
Year
Per Pay Month Day
Per Plan
Year
Per Pay
Per Plan
Year
Per Pay Month Day
Signature: Date:
VISION PLAN
National Vision
Administrators
3) Family
$7.02
2) Single +1
$5.13
$2.70
1) Single
NO CHANGES:
Current
Change to
Current
Change to
Employee
Spouse
Sun Life Voluntary Accidental Death & Dismemberment Insurance
Dependent(s)
Spouse
Employee
NO CHANGES:
Check to Decline Vol
AD&D:
NO CHANGES:
Current Coverage:
I understand that certain benefits require insurance applications and/or health statements and if I do not complete the required forms, I will
not be covered for those benefits. I understand that certain amounts of Voluntary Term Life Insurance may require insurance carrier
approval. I agree to the salary reductions shown on this worksheet to fund my Benefit Elections on a pre-tax or after-tax basis
Contribution Amount
Contribution Amount
AmeriFlex Dependent Care Spending Account
Current
Change to
Dependent(s)
AmeriFlex Medical Spending Account
Current
Change to
Sun Life Voluntary Term Life Insurance
Check to Decline Med
Spending:
Check to Decline Dep
Spending:
Check to Decline
Vision:
Check to Decline Vol
Life:
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2018 2019 Open Enrollment Worksheet 04182018

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Completed 17 November 2019

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