Fillable BANKW Staffing Medical Plan Contract Employees Offer of (BANKW Staffing)

Fill Online, Printable, Fillable, Blank BANKW Staffing Medical Plan Contract Employees Offer of (BANKW Staffing) Form

Use Fill to complete blank online BANKW STAFFING pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

BANKW Staffing Medical Plan Contract Employees Offer of (BANKW Staffing)

On average this form takes 3 minutes to complete

The BANKW Staffing Medical Plan Contract Employees Offer of (BANKW Staffing) form is 4 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 12 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your BANKW Staffing forms online.

BROWSE BANKW STAFFING FORMS
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
BANKW Staffing Medical Plan Contract Employees
Offer of Coverage | Benefit Summary Guide | Election Forms
Effective December 1, 2020 – November 30, 2021
Offer of Coverage
We are pleased to provide you with information about the BANKW Staffing Medical Plan. This notice describes eligibility
requirements for the Medical Plan and explains our procedures for electing coverage. Please review this information
carefully.
The Affordable Care Act and IRS require us to make an offer of coverage to all employees who may be eligible for medical
benefits. A contract employee will be eligible to participate in the Medical Plan if the employee is a common law employee
of BANKW Staffing, LLC (the “Company”), and its affiliated companies, KBW Financial Staffing & Recruiting, Alexander
Technology Group, The Nagler Group, Sales Search Partners and /or KNF&T (together with the Company, the Companies”)
and is considered to be “full-time”. We determine whether a contract employee is full-time using the rules set forth in
Eligibility Policy for Contract Employees. All other plan documents can be found here
.
At the time of hire, we will provide each contract employee, electronically, with a notice describing the coverage available
under our Medical Plan, as well as enrollment instructions.
If the contract employee elects coverage under our Medical Plan within the 30-calendar day period, the coverage will begin
on the 90th day following the commencement of employment, so long as the employee is determined be a full-time employee
as of the 90th day, and will continue for the duration of the Initial Measurement Period, provided the employee remains
employed at the Companies. A contract employee who is not determined to be “full time” as of the 90th day following
commencement of employment will not be eligible for coverage during the employee’s Initial Measurement Period. Please
carefully review the below polices and information carefully. In the event of any conflict between the content of this notice
and the policy, the policy controls.
To elect coverage, please complete and return the medical plan election form(s) below with your intention to enroll
within 30 calendar days of the original date-of-hire. You may send the form via email hr@bankwstaffing.com
or fax 1-
866-313- 4798. Once received, you will receive an email with further instructions and be granted login access to our online
benefit management system. During the registration process you will be required to enter and confirm personal identifying
data and ensure your current medical enrollment is correct. Your online enrollment in medical plan must be completed by
your eligibility date.
Additionally, the Affordable Care Act created an online marketplace to find, compare and purchasing health insurance
coverage, referred to as a Health Insurance Marketplace, or Exchange. Please view The Healthcare Exchange Notice
to
review details. If you purchase coverage through the Marketplace, you may be eligible for a federal subsidy that lowers your
monthly premiums or reduces your cost sharing. However, to receive these federal savings, you cannot be eligible for health
plan coverage through the Company that is affordable and provides "minimum value." More information on the health
care reform law and the Marketplaces is available at www.healthcare.gov .
Employee Acknowledgement: I acknowledge I have received the BANKW Staffing Offer of Coverage, polices and
information about eligibility and election process described above.
Employee
Signature:
Printed Name:
Date:
Contract employees must notify the Company within 30 calendar days of the original date-of-hire (whether or
not the employee is employed with the Company for the entire 30-day period) as to whether or not the contract
employee will choose to enroll in or waive coverage under our Medical Plan for the Initial Measurement Period.
If the contract employee does not respond within that period, the Company will assume the contract employee has
chosen to waive coverage for the Initial Measurement Period. Otherwise, your next opportunity to elect coverage will
be during the Standard Stability Period, under the look-back measurement method for Ongoing Employees as outlined
in the
Eligibility Policy for Contract Employees, unless you have a qualifying special enrollment or status change
event under applicable law.
BANKW Staffing Harvard Pilgrim Health Care HMO HSA | Summary & Election Form
Effective December 1, 2020 – November 30, 2021
The HMO HSA plan is only available to employees who reside inside the Harvard Pilgrim Health Care New England Service Area
Provider Name Harvard Pilgrim Health Care of New England
Provider Phone Number 1-888-333-4742
Provider Web Address www.harvardpilgrim.org
Plan Feature Harvard Pilgrim Best Buy HMO HSA
(3974/Rx1337)
Are Referrals Required?
No
Preventative Care
Covered in full
Office Visit
Deductible, then no charge
Specialist Visit
Deductible, then no charge
Plan Year Deductible
$6,000 individual / $12,000 family
Out-of-Pocket Maximum (includes all cost
sharing)
$6,500 individual / $13,000 family
Inpatient/Outpatient Facility Services
Deductible, then no charge
Outpatient Speech/Physical/ Occupational
Therapies
Deductible, then no charge – maximum of 60 visits combined
Lab X-ray and Ultrasound
Deductible, then no charge
High Cost Diagnostics
(MRI,MRA,CTA,CT,PET,SPECT)
Deductible, then no charge
Chiropractic Coverage
Deductible, then no charge - maximum of 12 visits
Emergency Room / Urgent Care
*ER copay waived if admitted
Deductible, then no charge
Deductible, then no charge
Prescription Drug Coverage
Deductible, then $5 / $20 / 20% / 30%
MEDICAL PLAN – WEEKLY COST FOR CONTRACT EMPLOYEES
Coverage Enrollment Options: Employee EE&Spouse EE&Child(ren) Family
Your Pay Rate $14.99/hour or under $35.08 $176.32 $153.31 $271.23
Your Pay Rate $15.00/hour-18.49/hour $43.85 $185.20 $162.19 $280.11
Your Pay Rate $18.50/hour & above $54.23 $195.49 $172.48 $290.40
HPHC HMO HSA MEDICAL PLAN ELECTION FORM
To elect coverage, please complete and return this medical plan election form with your intention to
enroll within 30 calendar days of the original date-of-hire. You may send the form via email
hr@bankwstaffing.com
or fax 1-866-313- 4798. Once received, you will receive an email with further instructions
and be granted login access to our online benefit management system. During the registration process you will
be required to enter and confirm personal identifying data and ensure your current benefit enrollment is correct.
Your online enrollment in benefits must be completed by your benefit eligibility date.
Employee Acknowledgement:
I acknowledge that the documents describing the terms and conditions of coverage, coverage options, and costs
of coverage under the BANKW Staffing, LLC Medical Plan – Harvard Pilgrim Best Buy HSA HMO (the “Medical
Plan”), were provided to me electronically via email, prior to my eligibility to join the plan. I acknowledge that all
relevant Medical Plan documents for contractor employees are posted on the Company’s website
www.bankwstaffing.com and that I may request a paper copy of any relevant plan document(s), free of charge,
by contacting Human Resources at 603-637-4510. I have had the opportunity to review these documents in
advance of my election, and I understand that if I have any questions about the Medical Plan, I may contact
Human Resources at 603-637-4510. I understand that if I enroll in Medical Benefits, I am making a binding
election concerning my benefits and authorizing payroll deductions on a pre-tax basis for the medical plans
elected through my employer-sponsored Section 125 Cafeteria Plan.
Employee Signature:
Printed Name:
Date:
Human Resources Department hr@bankwstaffing.com | 603-637-4510
BANKW Staffing Harvard Pilgrim Health Care PPO HSA | Summary & Election Form
Effective May 1, 2021 – November 30, 2021
The PPO HSA plan is only available to employees who reside outside of the Harvard Pilgrim Health Care New England Service
Area. The New England Service area includes Maine, New Hampshire, Massachusetts, Vermont, Rhode Island and
Connecticut.
Provider Name Harvard Pilgrim Health Care of New England
Provider Phone Number 1-888-333-4742
Provider Web Address www.harvardpilgrim.org
Plan Feature (In-Network) Harvard Pilgrim Best Buy PPO HSA
(3981/Rx1337)
Are Referrals Required?
No
Preventative Care
Covered in full
Office Visit
Deductible, then no charge
Specialist Visit
Deductible, then no charge
Plan Year Deductible
$6,000 individual / $12,000 family
Out-of-Pocket Maximum (includes all cost
sharing)
$6,500 individual / $13,000 family
Inpatient/Outpatient Facility Services
Deductible, then no charge
Outpatient Speech/Physical/ Occupational
Therapies
Deductible, then no charge – maximum of 60 visits combined
Lab X-ray and Ultrasound
Deductible, then no charge
High Cost Diagnostics
(MRI,MRA,CTA,CT,PET,SPECT)
Deductible, then no charge
Chiropractic Coverage
Deductible, then no charge - maximum of 12 visits
Emergency Room / Urgent Care
*ER copay waived if admitted
Deductible, then no charge
Deductible, then no charge
Prescription Drug Coverage
Deductible, then $5 / $20 / 20% / 30%
MEDICAL PLAN – WEEKLY COST FOR CONTRACT EMPLOYEES
Coverage Enrollment Options: Employee EE&Spouse EE&Child(ren) Family
Your Pay Rate $14.99/hour or under $35.08 $187.47 $162.60 $290.11
Your Pay Rate $15.00/hour-18.49/hour $43.85 $196.24 $171.37 $298.88
Your Pay Rate $18.50/hour & above $54.23 $206.63 $181.75 $309.27
HPHC PPO HSA MEDICAL PLAN ELECTION FORM
To elect coverage, please complete and return this medical plan election form with your intention to
enroll within 30 calendar days of the original date-of-hire. You may send the form via email
hr@bankwstaffing.com
or fax 1-866-313- 4798. Once received, you will receive an email with further instructions
and be granted login access to our online benefit management system. During the registration process you will
be required to enter and confirm personal identifying data and ensure your current benefit enrollment is correct.
Your online enrollment in benefits must be completed by your benefit eligibility date.
Employee Acknowledgement:
I acknowledge that the documents describing the terms and conditions of coverage, coverage options, and costs
of coverage under the BANKW Staffing, LLC Medical Plan – Harvard Pilgrim Best Buy HSA HMO (the “Medical
Plan”), were provided to me electronically via email, prior to my eligibility to join the plan. I acknowledge that all
relevant Medical Plan documents for contractor employees are posted on the Company’s website
www.bankwstaffing.com and that I may request a paper copy of any relevant plan document(s), free of charge,
by contacting Human Resources at 603-637-4510. I have had the opportunity to review these documents in
advance of my election, and I understand that if I have any questions about the Medical Plan, I may contact
Human Resources at 603-637-4510. I understand that if I enroll in Medical Benefits, I am making a binding
election concerning my benefits and authorizing payroll deductions on a pre-tax basis for the medical plans
elected through my employer-sponsored Section 125 Cafeteria Plan.
Employee Signature:
Printed Name:
Date:
Human Resources Department hr@bankwstaffing.com | 603-637-4510
BANKW Staffing Northeast Delta Dental | Summary & Election Form
Effective December 1, 2020 – November 30, 2021
Dental Summary Guide & Election Form
Provider Name Northeast Delta Dental
Provider Phone Number 800-832-5700
Provider Web Address www.nedelta.com/Home
PPO plus Premier
Plans Pay
In & Out of Network
Diagnostic & Preventive
Services
100% (no waiting period)
Basic Services
80% (no waiting period)
Major Services
50% (6 month waiting period)
Orthodontics (Child & Adult)
$1,500 per member lifetime
maximum
50% (6 month waiting period)
One-time Deductible
$100 per person / $300 per family
Calendar Year Maximum
$2,000 per person
Carryover
Carryover Threshold
Carryover Amount
Double-Up Max Limit
Yes
$500
$250
$2000
If this Northeast Delta Dental plan is replacing an existing group dental plan that covers the services to which the
waiting periods apply, the waiting periods will be waived for enrollees whose effective date of coverage coincides with
the original effective date of this plan.
DENTAL PLAN – WEEKLY COST FOR CONTRACT EMPLOYEES
Coverage Enrollment Options: Employee EE&Spouse EE+ Child EE&Child(ren) Family
Rates $12.61 $23.09 $23.09 $40.19 $40.19
DENTAL PLAN ELECTION FORM
To elect coverage, please complete and return this dental plan election form with your intention to enroll
within 30 calendar days of the original date-of-hire. You may send the form via email
hr@bankwstaffing.com
or fax 1-866-313- 4798. Once received, you will receive an email with further instructions and be granted login
access to our online benefit management system. During the registration process you will be required to enter
and confirm personal identifying data and ensure your current benefit enrollment is correct. Your online
enrollment in benefits must be completed by your benefit eligibility date.
Employee Acknowledgement:
I acknowledge that the documents describing the terms and conditions of coverage, coverage options, and costs
of coverage under the BANKW Staffing, LLC Dental Plan, were provided to me electronically via email, prior to
my eligibility to join the plan. I acknowledge that all relevant Dental Plan documents for contractor employees
are posted on the Company’s website www.bankwstaffing.com
and that I may request a paper copy of any
relevant plan document(s), free of charge, by contacting Human Resources at 603-637-4510. I have had the
opportunity to review these documents in advance of my election, and I understand that if I have any questions
about the Medical Plan, I may contact Human Resources at 603-637-4510. I understand that if I enroll in Medical
Benefits, I am making a binding election concerning my benefits and authorizing payroll deductions on a pre-tax
basis for the medical plans elected through my employer-sponsored Section 125 Cafeteria Plan.
Employee Signature:
Printed Name:
Date:
Human Resources Department hr@bankwstaffing.com | 603-637-4510
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

BANKW Staffing Medical Plan Contract Employees Offer of (BANKW Staffing)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 7 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document