HEALTH INSURANCE INFORMATION
Initial enrollment eligibility after 90 days of FT employment Employee Pre-Tax Bi-Weekly Payroll Deductions
Employee: 9.86% of net taxable pay
9.86% of net
taxable pay
(for Self)
plus >>> for
dependents
Employee/Spouse:
Employee/1 Child:
Employee/Children:
Family:
$311.20
$311.20
$683.62
$683.62
Cigna
MVP H.S.A.
Please mark your selection for each benet below. Please check the box next to cost of your plan & initial. I elect (or waive) coverage for 2019-20 as follows:
DOWNTOWN BROOKLYN
151 Lawrence Street
Brooklyn, NY 11201
Tel: 718 - 522-9073
HIALEAH
530 West 49th Street
Hialeah, FL 33012
Tel: 786-279-2643
MIDTOWN MANHATTAN
1293 Broadway/One Herald Center
New York, NY 10001
Tel: 212-672-6450
WWW.ASA.EDU
2019-2020 INSURANCE BENEFITS ELECTION FORM
FOR FULL TIME EQUIVALENT (FTE) EMPLOYEES (30-39 hours/wk)
________________
Date
________________________________
Signature
_____________________________________
ASA College Human Resources Oce (Date rec’d)
EMPLOYEE INFORMATION
Name (Last, First):
Home Address:
(Include City, State, Zip)
Employee ID:
Date of FT Hire:
SS#:Telephone #:
Date of Birth:E-mail address:
Gender:
Dependent #1 Date of Birth:
Relationship:
Gender: SS#
DEPENDENT INFORMATION
Name (Last, First):
Dependent #2 Date of Birth:
Relationship:
Gender: SS#
Name (Last, First):
Dependent #3 Date of Birth:
Relationship:
Gender: SS#
Name (Last, First):
Dependent #4 Date of Birth:
Relationship:
Gender: SS#
Name (Last, First):
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signature
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