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ENROLLMENT

Gender
Marital Status
MEDICAL
I have declined to enroll for coverage for myself, my spouse, and my dependent children due to:
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Base ($5000 Deductible-2) PPO
Semi-Monthly (24x) Payroll Deductions
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Buy-Up ($2500 Deductible-1) PPO
Semi-Monthly (24x) Payroll Deductions
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DENTAL
WAIVE COVERAGE
Value Plan
Semi-Monthly (24x)
Plus Plan
Semi-Monthly (24x)
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Vision
WAIVE COVERAGE
Vision Coverage
Semi-Monthly (24x)
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Dependent Information
Gender
Medical
Dental
Vision
Gender
Medical
Dental
Vision
Gender
Medical
Dental
Vision
Gender
Medical
Dental
Vision
Gender
Medical
Dental
Vision
Gender
Medical
Dental
Vision
Gender
Medical
Dental
Vision
Gender
Medical
Dental
Vision
Gender
Medical
Dental
Vision
Basic Life & AD&D / $10,000 Benefit - Available to all Full Time Employees (Employer Paid)
Please note that if the beneficiary is a minor, you will need to set-up a trust
Employee Voluntary Life/AD&D: Increments of $10,000 to a Max of $300,000 - Guarantee Issue of $100,000
EE Coverage
Spouse Voluntary Life/AD&D: Increments of $5,000 to a Max of $100,000 - Guarantee Issue of $25,000
SP Coverage
Child/ren Voluntary Life/AD&D: $10,000
CH Coverage

Please note that if coverage is not elected during initial enrollment, a physical examination or further medical information is required if applying for coverage at a later date. This will be at your own expense.

AN EVIDENCE OF INSURABILITY FORM(S) MUST BE COMPLETED FOR ANYONE ELECTING VOLUNTARY LIFE COVERAGE ABOVE THE SPECIFIED GUARANTEE ISSUE AMOUNT, OR FOR LATE ENTRANTS, EMPLOYEE / DEPENDENT(S) WHO ARE INCREASING THEIR VOLUNTARY BENEFIT. 

 

* Dependents are eligible for Voluntary Life coverage only if you have elected coverage for yourself.

Voluntary Life & AD&D - Available to all Full Time Employees (Employee Paid)
Beneficiary Information