WWW.ASA.EDU
2019-2020 INSURANCE BENEFITS ELECTION FORM
FOR FULL TIME (FT) EMPLOYEES
________________
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: Salary:
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):
Non scholae, sed vitae discimus!
ADDITIONAL BENEFITS***
***If electing any of these benefits, please complete separate Guardian enrollment form(s).
Voluntary Life: Elect
Decline
Accident Plan: Elect
Decline
Critical Illness Plan: Elect
Decline
HEALTH INSURANCE INFORMATION
Initial enrollment eligibility after 90 days of FT employment Employee Pre-Tax Bi-Weekly Payroll Deductions
Employee:
Employee/Spouse:
Employee/1 Child:
Employee/Children:
Family:
Decline / Waiver**:
**Note: If waiving coverage, you must also complete ASA waiver forms.
$0.00
$118.23
$495.34
$495.34
$929.01
$929.01
$0.00
$78.91
$414.61
$414.61
$800.66
$800.66
$0.00
$0.00
$2.43
$3.69
$3.69
$6.49
$6.49
$22.01
$42.80
$42.80
$73.21
$73.21
$6.32
$11.48
$11.48
$20.73
$20.73
Cigna Opt. #1 Cigna Opt. #2 Guardian Vision Guardian Dental
PPO Plan HMO Plan*
Medicare
Trad. EPOc H.S.A. Plan PPO Plan(Age 65+ Only)
$0.00
$0.00
$0.00
MDG Dentist Code # (for HMO Dental Plan enrollees)*: Self Spouse Children
*To find participating dentists for HMO dental plan, please go to www.guardiananytime.com. Then, enter the dentist’s code number.
See separate
packet for
additional,
Voluntary
Benet
options.
Life Insurance,
Accident plan
& Critical
Illness plan.
YOU PAY
ADDED
COST FOR
SPOUSE
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:
click to sign
signature
click to edit
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