Fillable BIRDVILLE ISD BENEFITS CHANGE FORM

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BIRDVILLE ISD BENEFITS CHANGE FORM

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BIRDVILLE ISD BENEFITS CHANGE FORM
Employee Name (First, Middle, Last)
Employee ID#
Date of Birth Contact Phone Number
CHECK REASON FOR CHANGE (QUALIFYING EVENT):
Birth/Adoption/Legal Guardianship change of a child
Death of a dependentMarriage/Div
orce
Change in dependent eligibility
Gain/loss of other coverage Other _________________________________
D
ate of Qualifying Event (if applicable) ______
__________________ (required support documentation is listed on page 2)
PLEASE TELL US WHAT YOU WANT YOUR NEW COVERAGE TO BE BELOW
COVERAGE
CXL
ENROLL/CHANGE COVERAGE TIER TO
ENROLL/CHANGE PLAN LEVEL OR AMOUNT TO
Medical (TRS)
EE EE and SP EE and CH Family
AC HD AC Primary AC Primary+ Scott & White
Hospital Indemnity Plan (The Hartford)
EE EE and SP EE and CH Family
Plan 1 ($1,500) Plan 2 ($2,500)
Cancer (American Public Life)
EE EE and CH EE, SP and/or CH Level 1 Level 1 + ICU Level 2 Level 2 + ICU
Disability (Cigna)
Premium Plan Select Plan
Wa
iting Period (days)
□ 7 □ 14 □ 30 □ 60 □ 90 □ 180
Monthly Coverage Amount $
Group Term Life (One America)
EE Spouse
Child(ren)
EE $ SP $ CH $10,000
AD&D (One America)
EE Family
Amount $
Dental (Delta)
EE EE and SP EE and CH Family
DHMO
PPO Low
PPO High
Vision (Superior)
EE EE and SP EE and CH Family
ID Theft Protection (IDGuard)
Employee Family
Total (1 bureau)
Premier (3 bureau)
Legal Services (MetLaw)
Family
Medical Reimbursement Plans (EECU/NBS)
HSA
FSA (Check only one)
Amount Per Pay Period $
Dependent Care Reimbursement (NBS)
Amount Per Pay Period $
Emergency Transport (MASA)
Family
CONTINUED ON NEXT PAGE
Rev. 09/2020
PLEASE ENTER A (ADD) OR D (DELETE) OR LEAVE BLANK THE BOXES BELOW FOR EACH BENEFIT
EMPLOYEE/DEPENDENT NAME
Date of
Birth
Medical
HIP
Cancer
Grp Term
Life
AD&D
Individual
Life
Vision
ID Theft
Legal
Emergency
Transport
Important: I understand and have verified the benefit selections I have made and authorize any payroll deductions required for those selections. I also
understand the above selections may not be changed during the year unless I have a qualified change in family status as defined by the Internal Revenue
Service. I understand that any requests for such a change must be submitted in writing to my benefits contact within 31 days of the qualifying event. Any
addition of coverage will be effective the first day of the month following the qualifying event. I will be responsible for paying back any missed premiums.
Any deletion of coverage will be effective the 1st of the month following the signature date.
Signature: _________________________________________________________________ Date: _______________________
Fax to the Benefits Office @ 817-547-5580 or email to susan.dippolito@birdvilleschools.net
QUALIFYING EVENT SUPPORT DOCUMENTATION REQUIREMENTS:
Marriage – submit a copy of the marriage certificate.
Divorce – submit a copy of the Dissolution of Marriage.
Birth of Child – submit documentation of birth from the hospital, such as a Proof of Vital Facts. When received, please enter the dependent’s social
security number via THEbenefitsHUB.
Adoption/Legal Guardianship – submit certified court paperwork.
Loss of other coverage or change – provide proof of loss of coverage such as a COBRA letter or notice from the employer.
Gain other coverage (other group coverage or Marketplace coverage) – provide proof of other coverage such as a copy of the new card or
enrollment confirmation.
Rev. 09/2020
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BIRDVILLE ISD BENEFITS CHANGE FORM

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Completed 2 December 2020

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