Groups electing Ameritas PPO plans with 10 or more
employees qualify for takeover benefits by submitting
1) Group’s most recent prior dental billing statement;
2) Statement from 12 months prior to effective date;
3) and 12 months prior showing Ortho for Ortho
(6 of 6)
Optional Benefits Application
When electing dental coverage, the undersigned employer hereby applies for membership in the Bankers Life Nebraska Preferred Trust.
*Ameritas PPO plans with Ortho
are only available to groups with
5 or more eligible employees
Complete numbers 1-6 below for buy up dental plans only
ll buy-up dental plans: MetLife DHMO, SmileSaver DHMO and Ameritas PPO plans WITHOUT Ortho
ll buy-up dental plans: MetLife DHMO, SmileSaver DHMO and Ameritas PPO* plans WITH Ortho
ll voluntary dental plans: MetLife DHMO, SmileSaver DHMO and Ameritas PPO plans WITHOUT Ortho
(Do not complete for voluntary dental plans)
1. Total number of employees applying for dental coverage
2. Total number of COBRA eligibles applying for dental coverage
3. Percentage of employee-only premium paid by Employer
4. Percentage of dependent premium paid by Employer
5. Employer contribution is based on plan
6. Does your group currently have dental?
1000 3000 3500 4000 5000
% (Employer must
ay a minimum of 50%)
% (write 0 if none)
If yes, carrier name
Check this box if you would like to offer Voluntary Vision to your employees. Employees are responsible for 100% of this cost if they enroll in this coverage.
Landmark Healthplan, Inc.
Chiropractic Only Chiropractic & Acupuncture
Assurity Life Insurance Company
OPTION 1: Flat Amount
Select a Flat amount for
2. # of eligible
OPTION 2: Scheduled Amount
Select up to 4 amounts with the highest
being NO MORE THAN 2.5 X the lowest.
(amounts must be in increments of $5,000)
Section 125 — Premium Only Plan
CONEXIS Benefit Administrators (a division of WageWorks)
Participation Limitations - P.O.P. rules require that all participants in the plan be employees. Please be advised that 2% (or greater) shareholders in an S-Corporation, Sole
Proprietors in a Sole Proprietorship and Partners in a Partnership are not considered employees as defined by Tax Code, and therefore, are ineligible to participate in the P.O.P.
IMPORTANT: Read the information provided in the CaliforniaChoice Employer Optional Benefits Guide pertaining to the Section 125 Premium Only Plan and the tax consequences.
Name of Company President, Principal, or Partners Name of Corporate Secretary (if applicable)
5. Company Structure
State of Incorporation or Domicile (if applicable)
Plan Number (usually 501)
(If not indicated, 501 will be used)
6. Premium payments may be elected for
7. Last day of first Plan year
(If not indicated, last day of medical plan year will be used)
Usually 12 months after the effective date of coverage;
subsequent plan years will be the 12 month period following this date.
(i.e. management, executives, etc.)
Employer Signature Print Name
When electing vision coverage, the undersigned employer hereby applies for membership in the Bankers Life Nebraska Preferred Trust. Provided by Ameritas.
100% of all eligible employees (whether enrolling or waiving
medical) must enroll for life coverage.
◄CHOOSE ONE OPTION ONLY►
Guaranteed Issue Amounts available for both Options
Amounts in between available in increments of $5,000
*Employees must fall under classification to
qualify for specified amount
MetLife DHMO/SmileSaver DHMO/Ameritas (PPO)
CC 0201E 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
ll voluntary dental plans: MetLife DHMO, SmileSaver DHMO and Ameritas PPO* plans WITH Ortho
SmileSaver DHMO Ameritas PPO
(Check one box only)