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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:
Base ($5000 Deductible-2) PPO
Semi-Monthly (24x) Payroll Deductions
Buy-Up ($2500 Deductible-1) PPO
Semi-Monthly (24x) Payroll Deductions
DENTAL
WAIVE COVERAGE
Value Plan
Semi-Monthly (24x)
Plus Plan
Semi-Monthly (24x)
Vision
WAIVE COVERAGE
Vision Coverage
Semi-Monthly (24x)
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
Please note that if the beneficiary is a minor, you will need to set-up a trust
Voluntary Short Term Disability - Max Benefit of $1,000 per week not to exceed 60% of your earnings
Voluntary Short Term Disability
Voluntary Long Term Disability - Max Benefit of $6,000 per month not to exceed 60% of your earnings
Voluntary Long Term Disability

I authorize Moore Control Systems, Inc. to deduct the cost of any elected benefits for medical, dental, vision and FSA benefits from my pay on a pre-tax basis, as authorized under the 125 plan. I further authorize Moore Control Systems, Inc. to deduct the cost of any elected benefits for life and disability benefits on an after-tax basis. I declare that all entries on this form are true and complete and that any material misstatements or failure to report information may be used as the basis for cancellation of coverage for me and my dependent(s) (if any) from the original effective date of coverage. If I am not actively at work or are unable to engage in all the usual duties of a person of like age and sex, the effective date of all non-medical coverage will be delayed until I return to work and resume usual duties. A photographic copy of this authorization shall be valid as the original.
 

I understand that elections (including elections not to participate) will continue for the entire plan year unless there is a change event as described in the 125 plan such as the formation of a new dependent relationship as a result of marriage, birth, or adoption or the dissolution of a relationship such as divorce, or loss of other coverage, I must request an election change within 31 days after such event.

I understand that my dependent(s) and I may be considered a Late Enrollee(s) subject to a longer preexisting condition exclusion limitation if we don’t enroll when initially eligible.

Enrollment Received, Thank you!
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