Fillable 5-1-17 Open Enrollment 2017 2018 Worksheet 042617 (Wilkes University)

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5-1-17 Open Enrollment 2017 2018 Worksheet 042617 (Wilkes University)

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Wilkes University
Flexible Benefits Worksheet
June 1, 2017 To May 31, 2018
NAME:
WIN:
SSN:
Please Circle
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
Change to:
Plan: Plan:
Tier: Tier:
Check to Decline
Medical:
Check to Decline
Dental:
Must provide proof of other
medical coverage to receive
$50 per pay
EFFECTIVE DATE:
2) Family
$26.76
$39.12
Current Coverage:
NO CHANGES:
1) Single
$9.97
$14.61
Current Coverage:
DENTAL INSURANCE PLANS
A) United Concordia
Basic
B) United
Concordia
Enhanced
NO CHANGES:
$185.17
$215.15
$250.47
$275.09
$13.24
$98.61
$114.33
$133.39
$146.52
5) Family
A) PPO Blue
$400 Deductible
$206.92
$240.41
$279.87
$307.38
2) Parent & Child
3) Parent & Children
4) Employee & Spouse
Please provide the following information for all persons to be covered under the medical (M) , dental (D)
and vision (V) plans.
DATE OF BIRTH
MEDICAL INSURANCE PLANS
1) Single
B) Blue Care HMO
C) PPO Blue $1000
Deductible
$48.93
$61.50
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:
Check to Decline Med
Spending:
Check to Decline Dep
Spending:
Check to Decline
Vision:
Check to Decline Vol
Life:
NO CHANGES:
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
Effective Date
Dependent(s)
AmeriFlex Medical Spending Account
Current
Change to
Effective Date
Sun Life Voluntary Term Life Insurance
Employee
Spouse
Sun Life Voluntary Accidental Death & Dismemberment Insurance
Dependent(s)
Spouse
Employee
NO CHANGES:
Check to Decline Vol
AD&D:
NO CHANGES:
Current
Change to
Effective Date
Current
Change to
Effective Date
2) Single +1
$8.27
Current Coverage:
3) Family
$11.31
$4.35
VISION PLAN
Vision Benefits of
America
1) Single
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5-1-17 Open Enrollment 2017 2018 Worksheet 042617 (Wilkes University)

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Completed 24 July 2020

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