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    Staffing Selection Form - 2.2020

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    eric.risner
    This document contains an employee benefits selection form for medical, dental, and vision insurance plans offered by TriStaff Group of Companies. It lists the coverage options and associated costs for each plan. The employee must sign to authorize TriStaff to deduct premium payments from their wages. If declining coverage, the employee must state their reason for doing so and sign a declination statement acknowledging the late enrollment warning. Exceptions allow an employee to enroll later if other coverage ends or a new dependent is acquired within 30 days.

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    Staffing Selection Form - 2.2020

    Uploaded by

    eric.risner
    51 views2 pages
    This document contains an employee benefits selection form for medical, dental, and vision insurance plans offered by TriStaff Group of Companies. It lists the coverage options and associated costs for each plan. The employee must sign to authorize TriStaff to deduct premium payments from their wages. If declining coverage, the employee must state their reason for doing so and sign a declination statement acknowledging the late enrollment warning. Exceptions allow an employee to enroll later if other coverage ends or a new dependent is acquired within 30 days.

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    TriStaff Group

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    This document contains an employee benefits selection form for medical, dental, and vision insurance plans offered by TriStaff Group of Companies. It lists the coverage options and associated costs for each plan. The employee must sign to authorize TriStaff to deduct premium payments from their wages. If declining coverage, the employee must state their reason for doing so and sign a declination statement acknowledging the late enrollment warning. Exceptions allow an employee to enroll later if other coverage ends or a new dependent is acquired within 30 days.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    51 views2 pages

    Staffing Selection Form - 2.2020

    Uploaded by

    eric.risner
    This document contains an employee benefits selection form for medical, dental, and vision insurance plans offered by TriStaff Group of Companies. It lists the coverage options and associated costs for each plan. The employee must sign to authorize TriStaff to deduct premium payments from their wages. If declining coverage, the employee must state their reason for doing so and sign a declination statement acknowledging the late enrollment warning. Exceptions allow an employee to enroll later if other coverage ends or a new dependent is acquired within 30 days.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    CA STAFFING EMPLOYEE BENEFITS SELECTION FORM

    If you are enrolling for the first time or changing plans and/or coverage level, you must complete an insurance carrier enrollment form.

    EMPLOYEE NAME ____________________________________ Plan Year: January 1, 2020 – December 31, 2020
    A. MEDICAL Total Monthly Cost TriStaff Weekly Cost Employee Weekly Cost
    Employee Only $513.87 $80.44 $38.14
    Sharp Health Plan Employee + Spouse/DP $1,130.52 $80.44 $180.45
    HMO HSA - LOW Employee + Child(ren) $924.96 $80.44 $133.01
    Employee + Family $1,593.00 $80.44 $287.17

    Employee Only $133.75 $24.00 $6.87


    MEC Plus Advantage Employee + Spouse/DP $218.24 $24.00 $26.36
    Employee + Child(ren) $202.24 $24.00 $22.67
    Employee + Family $293.30 $24.00 $43.68
    B. DENTAL Total Monthly Cost TriStaff Weekly Cost Employee Weekly Cost
    Employee Only $19.60 $0.00 $4.52
    Anthem Employee + Spouse/DP $39.21 $0.00 $9.05
    Dental Net HMO Plan Employee + Child(ren) $39.21 $0.00 $9.05
    Employee + Family $63.70 $0.00 $14.70

    Employee Only $54.63 $0.00 $12.61


    Anthem Employee + Spouse/DP $111.44 $0.00 $25.72
    Dental Complete PPO Employee + Child(ren) $117.45 $0.00 $27.10
    Employee + Family $178.54 $0.00 $41.20
    C. VISION Total Monthly Cost TriStaff Weekly Cost Employee Weekly Cost
    Employee Only $8.62 $0.00 $1.99
    Anthem Blue Cross Employee + Spouse/DP $14.65 $0.00 $3.38
    Blue View Vision Employee + Child(ren) $15.52 $0.00 $3.58
    Employee + Family $23.27 $0.00 $5.37

    I authorize TriStaff Group of Companies to deduct from my wages the necessary payroll deductions, if any, for the coverages I have elected above. I understand
    that the premiums will be deducted on a pre-tax basis as established under my employer’s Section 125 plan. I understand that premiums for a Domestic Partner
    and Domestic Partner’s Children may be deducted on a post-tax basis.

    ____________________________________________________ _____________________________
    Employee’s Signature Date

    Marsh & McLennan Insurance Agency LLC company


    MEDICAL, DENTAL AND/OR VISION COVERAGE DECLINATION STATEMENT
    _________________________ _____________________
    Full Name of Employee (Print) Social Security Number
    If you wish to decline coverage for yourself and/or your dependent(s) who are eligible to enroll under our group medical, dental and/or vision plans, you
    must complete this form. Before declining coverage, please read the Late Enrollment Warning on the bottom of this form.
    If you are declining coverage under this plan because you and/or your eligible dependent(s) have coverage under another employer's benefit plan, please
    indicate that below. If you are declining enrollment for yourself or your dependents (including your spouse) because of other insurance coverage, you may in
    the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. In
    addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your
    dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. Note the exceptions in the Late
    Enrollment Warning so you know the circumstances in which you may enroll later in our plan without being considered a late enrollee.

    EMPLOYEE'S DECLINATION STATEMENT


    I acknowledge that I have been given the opportunity to enroll myself and (if applicable) my eligible dependents in my employer's benefit plans and
    have read the Late Enrollment Warning. I am declining to enroll the following eligible persons under the medical, dental and/or vision benefit plans:

    NAME RELATIONSHIP SOCIAL SECURITY


    NUMBER

    SELF SEE ABOVE

    REASON FOR DECLINING THIS COVERAGE: (Must be completed)


    Coverage Under Another Employer's (please check) and complete: Medical Dental Vision
    Employer Name: _________________________________________________________________________
    Plan Name/Insurance/HMO: _______________________Plan or Policy Number: _____________
    State or Federal Medical Program (i.e. CoveredCA, MediCal, Medicare, TriCare)
    Other Reason - Explain: __________________________________________________________________

    _________________________________ _____________________________________

    Signature of Employee Date

    LATE ENROLLMENT WARNING


    An employee or an employee's eligible dependent must be enrolled in the employer's benefit plan during the initial enrollment period (normally 30 days
    from the date the employee or dependent is first eligible to be covered). An employee or an employee's eligible dependent who requests enrollment
    after the initial enrollment period will be considered a Late Enrollee. There are some exceptions - see "Late Enrollee Exceptions" below.
    Late Enrollee Exceptions:
    1. Persons who decline coverage during their initial enrollment period because they have coverage under another employer's benefit plan (and
    indicate this reason for declining coverage), will not be considered Late Enrollees if:
    a. Their coverage under the other employer's medical benefit plan ends because of:
    1. Termination of employment or change of employment status.
    2. Termination of the other employer's benefit plan.
    3. The employer stops paying a required contribution for the person's coverage.
    4. Death of, or divorce from, the person through whom they were covered; and
    b. They request enrollment within 30 days after termination of coverage under the other employer's benefit plan.
    2. If the employer offers multiple benefit plans, a person will not be considered a Late Enrollee if they elect a different plan during an open
    enrollment period.
    3. A spouse or minor child who is enrolled within 30 days after issuance of a court order directing that coverage be provided for the person
    under a covered employee's benefit plan will not be considered a Late Enrollee.
    Marsh & McLennan Insurance Agency LLC company

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