Fillable New Hire Open Enrollment Rehire Last Name Gender (Town of Payson)

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New Hire Open Enrollment Rehire Last Name Gender (Town of Payson)

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The New Hire Open Enrollment Rehire Last Name Gender (Town of Payson) form is 2 pages long and contains:

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  • 29 check-boxes
  • 49 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Payson

BROWSE TOWN OF PAYSON (AZ) FORMS

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NEW HIRE/OPEN ENROLLMENT FORM
Forms must be submitted to Kairos within 30 days of the hire date, except as noted in the Plan Document/Summary Plan Description. Failure to
submit forms within the required period will impact the participant’s benefits and/or enrollment. Kairos is not responsible for untimely form
submission, or for lost forms.
Employer Name:
SECTION A: ENROLLMENT
New Hire Open Enrollment
Rehire
SECTION B: EMPLOYEE INFORMATION
First Name
M.I.
DOB (M/D/Y)
Gender
M
F
Zip
Last Name
SSN
Mailing Address
City
Marital Status S
M
Tier Selection
Active
Retiree
Board Member
SECTION C: DEPENDENT INFORMATION
Last Name, First, M.I.
SSN
Relationship to Employee
Gender
DOB (M/D/Y)
Dependents age 26 and older are not eligible to be enrolled for benefits, unless disabled.
If enrolling a domestic partner and allowed by your Employer, a statement of domestic partnership must be completed and submitted with this form.
SECTION D: MEDICAL
Select plan and who you wish to cover.
Employees and dependents must be enrolled in the same plan option.
Employee + Family
*See your Employer for details on embedded vs. non-embedded deductibles
If enrolling in the HDHP, I elect to contribute $________________ annually into my Health Savings Account (HSA).
(maximum of $3,550 annually for employee only / maximum of $7,100 for employee + dependents)
SECTION E: DENTAL AND VISION
Delta Dental
Employee Waive
Employee Waive
VSP Vision
Employee + Spouse
Employee + Spouse
Employee + Child(ren)
Employee + Child(ren)
Employee + Family
Employee + Family
SECTION F: BASIC LIFE BENEFICIEARIES
Last Name, First, M.I.
Relationship to Employee Percentage (must equal 100%)
Basic Life is 100% Employer sponsored; therefore, you cannot opt out of basic life coverage.
Copay Plan - $750
Embedded Deductible*
Employee
HDHP - $1,500/$3,000
Non-embedded Deductible*
Employee + Spouse
HDHP - $2,500/$5,000
Non-embedded Deductible*
Employee + Child(ren)
HDHP - $5,000/$10,000
Embedded Deductible*
Waive
Town of Payson
READ CAREFULLY
• I understand that certain benefits under this Plan are pre-tax. I authorize the deduction of health care premium payments from my before-tax pay that will be
applied to the cost of the coverages elected. I understand that the cost of coverage may be changed annually or as announced by my Employer.
• I understand that the premiums for domestic partner health benefits may not be paid on a pre-tax basis unless the domestic partner is eligible for tax free health
coverage under federal tax laws (e.g. is a tax qualified dependent).
• I understand that the benefits elected must remain in force for the entire Plan Year and that I may not make a change in my coverage or contribution during that
Plan Year, unless there is a qualified change in status as defined under the Plan in accordance with the Internal Revenue Code regulations.
Employee Signature Date
SECTION H: FOR HR USE ONLY—DO NOT WRITE BELOW THIS LINE
Date of Hire Coverage Effective Date Salary
If eligible due to full time status, enter date of full-time employment
Employer Signature Date
SECTION G: EMPLOYEE SIGNATURE
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New Hire Open Enrollment Rehire Last Name Gender (Town of Payson)

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Completed 9 February 2021

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