Fillable 201920 Benefits Enrollment Form Fillable (Hope College)

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201920 Benefits Enrollment Form Fillable (Hope College)

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The 201920 Benefits Enrollment Form Fillable (Hope College) form is 3 pages long and contains:

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  • 32 check-boxes
  • 113 other fields

Country of origin: US
File type: PDF

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Form 1-A
Benefits Enrollment Form
All employee contributions applicable to the benefits elected below will be withheld pre-tax, semi-monthly (unless otherwise noted).
Employee Last Name: Employee First Name :
Address: City, State ZIP:
Employee SSN: Employee Birthdate (MM/DD/YYYY):
Employee Gender: Male Female Employee Marital Status: Single Married
Health & Pharmacy
Plan Choice: BLUE Traditional Plan ORANGE Consumer–Driven High Deductible Health Plan* Waive Coverage
(affordable monthly cost, low out of pocket cost) (very low monthly cost; higher out of pocket cost) (no cost)
Level of Coverage: Employee Only Employee + 1 Family Member Employee + 2 or More Family Members
Dental
Plan Choice: Basic Dental Plan Dental Plan with Ortho Coverage for dep <age 19 Waive Coverage
Level of Coverage: Employee Only Employee + 1 Family Member Employee + 2 or More Family Members
If new, please provide previous dental provider and policy # if you wish to waive waiting period for Class III & IV Services):
________________________________________________________________________________________________________________________
Vision
Plan Choice: Insight Vision Plan Waive Coverage
Level of Coverage: Employee Only Employee + 1 Family Member Employee + 2 or More Family Members
Form 1-A
Health, Dental, & Vision Plan Family Members. Be sure to check the appropriate boxes for the coverages you elect for your dependents; you may
add any additional dependents on another form if needed.
First Name Last Name SSN
Date of
Birth
M/F Relationship
Health &
Pharmacy
Dental Vision
Spouse*
Dep-1
Dep-2
Dep-3
Dep-4
Dep-5
Dep-6
Dep-7
*Spouse’s Employment Status and Employer Information (if applicable):
Not Employed (surcharge does not apply)
Employed but no health benefits available through employer (surcharge does not apply)
Self Employed with no health benefits available to any employees including self (surcharge does not apply)
Employed with primary coverage through employer (surcharge does not apply)
Spouse employed at Hope College (surcharge does not apply)
Employed with health benefits available but not elected (surcharge applies)
Spouse’s Employer’s Name
Address
Phone Number
FSA/HSA Tax Savings Accounts (pre-tax): FSA account benefit dates are July 1 (or date of hire/eligibility, if later) – June 30 each benefit year. All FSA Accounts
annual elections
will be split and deducted from all pays (24 or those remaining) in benefit year. Upon enrollment, PNC Bank will email you additional enrollment instructions to complete your HSA account setup.
Decline to
Participate
Flexible Medical Account
(Must be enrolled in Traditional
Medical Plan ~ BLUE)
($2ϳϬ0 Benefit Year Max.)
ANNUAL Amount:__________
Health Savings Account
(Must be enrolled in HDHP
Medical Plan ~ ORANGE)
($3500*/Single or $7000*
Double/Fam Calendar Year Max.)
*If 55 or older, +1,000 catchup allowed
PER PAY Amount:_________
Limited Purpose Dental
& Vision Flexible Accoun
t
(Must be enrolled in HSA)
($2ϳϬ0 Benefit Year Max.)
ANNUAL Amount:__________
Flexible Dependent
Care Account
(No criteria to enroll; all eligible)
($5000 Benefit Year Max.)
ANNUAL Amount:__________
Form 1-A
Life/Accidental Death & Dismemberment & Long Term Disability Insurance (not available to visiting, term
assignment, RD, or RLC employees)
The College provides, at no cost, Basic Life Insurance equal to one times annual base salary plus $12,000 as well as Basic LTD Insurance of 60%
monthly benefit (up to plan maximums) through The Lincoln National Life Insurance Company. Please provide Beneficiary Designation below
which will apply to your Life and Accident coverages, including supplemental if elected below.
Name (Last, First, MI)
Relationship
% of Benefit
Primary Beneficiary - 1
Primary Beneficiary – 2
Contingent Beneficiary – 1
Contingent Beneficiary - 2
Optional Employee Supplemental Life Insurance (after-tax)
No Additional Coverage 1x 2x 3x 4x 5x 6x 7x
Coverage is offered at above factors of your base salary and will be rounded to the next higher 10,000. You must provide evidence of insurability for coverage above
$200,000. Please complete EOI and submit directly to insurance company for review.
Optional Dependent Supplemental Life Insurance (after-tax)
No Additional Coverage $__________ Coverage for Spouse* $10,000 Child Rider (for all dependent children under 19)
*Spouse coverage is available from $10,000-$250,000 in $10,000 increments, not to exceed 50% of the value of the level of Supplemental Life Insurance elected for
employee. Evidence of Insurability is required for coverage above $50,000. Please complete EOI and submit directly to insurance company for review.
Optional Employee Supplemental LTD insurance (after-tax)
No Additional Coverage Buy-Up (+10% monthly benefit up to plan maximums)
Retirement INVEST 403(b) Plan
All new hires must complete one year of benefit-eligible service at the College to receive the 10.5% employer contribution. All employees are
encouraged, and eligible immediately, to elect voluntary contributions (pre-tax or ROTH). To setup your account and elect contributions, sign in as “new user” at
hopecollege.trsretire.com
once your employee information is processed (normally 7-14 days from hire/start).
Employee Signature: Date:
NOTE: A PERSON MAY BE COMMITTING INSURANCE FRAUD, IF HE OR SHE SUBMITS AN APPLICATION OR CLAIM CONTAINING A FALSE OR DECEPTIVE
STATEMENT WITH INTENT TO DEFRAUD (OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD) AN INSURANCE COMPANY.
HR USE: Effective/Change Date: ____/_____/______ Change Reason: New HIre Open Enrollment Special Enrollment _________________ DOH: ___/___/___ Annual Salary: $_________ HRS/FTE: ______
PDAHIOC PDADEDN PDABCOV EMVP-H CM EMVP-D EM LIFE/LTD PNC RETIRE
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201920 Benefits Enrollment Form Fillable (Hope College)

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Completed 23 July 2020

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