If enrolling for employee-only coverage, stop here and return form

UNITED FOOD AND COMMERCIAL WORKERS LOCAL 400 AND EMPLOYERS HEALTH AND WELFARE FUND
2015 OPEN ENROLLMENT
PLAN 1000
Please complete and return to the Fund Office via mail, using the enclosed, prepaid envelope or fax to (304)345-2832
You may also log onto: WWW.UFCWL400HEALTHANDWELFARE.ORG to enroll via the Plan’s secure Open Enrollment system
1.
Employee Information
Last Name
First Name, M.I.
Mailing Address
City
Home Telephone
(
)
Please circle one:
Date of Hire
1. Single
2. Widowed
3. Separated
4. Married
5. Divorced
Employer Name
Separation Date ___________
Marriage Date ____________
Divorce Date ______________
Do you have a second job?
YES
NO
Employment status at second job Full-Time Part-Time
Date of Hire _____________
If YES, are you enrolled in health coverage? YES
NO
2.
M
Sex
Social Security #
F
Zip Code
(
Employer Address
Cell Phone
)
Employer Phone Number
Name of Spouse ___________________________________
Is other parent of children responsible for medical, vision and dental care?
*YES
NO
*If YES, please advise name of insurance carrier and effective date:
If YES, name & address of employer:
Employer phone number ______________
Is health coverage available at second job?
What Type(s) of Coverage is Available?
YES
Health
NO
Dental
Vision
RX
Previous and/or Other Health Information and/or Medicare Information: **PLEASE READ AND COMPLETE THIS SECTION THOROUGHLY**
•
If you have other medical coverage (including Medicare), you MUST complete this section and provide the requested
information.
•
If your coverage is terminated, please state reason:__________________________________________________
Name of Insurance Company or Plan or Medicare
3.
Date of Birth
/
/
State
Insurance Company Policy/ID#
Effective Date
Employee Coverage Election:
Employee Only Coverage available at a cost of $6.00 weekly made by Payroll Deduction.
I elect employee coverage only at a cost of $6.00 weekly (please circle one)
YES
Termination Date
NO
4. Statement of Understanding and Employee Authorization
I understand that by signing below, I am agreeing to the following:
•
•
•
I understand that any willfully false statement on this form can exclude me and my dependents from future coverage though the
Plan. If fraudulent misstatements were made, the Fund has the right to recover from me any amounts it should not have paid
and legal action may be taken at any time.
I affirm that I have reviewed all answers on this application and I verify that the answers are true, correct and complete to the
best of my knowledge.
I understand this election will remain in effect until the effective date of next open enrollment (or until I properly change my
election, if earlier). Further, by signing this form, I elect to pay my weekly contribution and authorize my employer to deduct the
amount elected above on a pre-tax basis through my employer’s cafeteria plan. I understand the payroll deduction must remain
in effect for the full coverage year and I will only be able to make changes as permitted in my employer’s cafeteria plan and as set
forth in the attached Notice of Special Enrollment Rights.
_____________________________________
_________________________________
EMPLOYEE NAME (PRINT)
___________________________________________________
EMPLOYEE SIGNATURE
SOCIAL SECURITY NUMBER
____________________________
DATE
____________________________
STORE NUMBER
******If enrolling for employee-only coverage, stop here and return form******
******To enroll for Dependent Coverage, please also complete reverse******
Mail completed form to:
UFCW Local 400 & Employers Health and Welfare Fund
600 D Street-Suite 250
South Charleston, WV 25303
OR - Fax: 304-345-2832
1
1.
Dependent Information: List only eligible dependents to be covered under the Plan. If a dependent’s name is different from yours, a copy of marriage
certificate, birth certificate, or other proof of custody must be attached to this form. Coverage is available for natural children, legally adopted children and
children placed for adoption up to age 26, regardless of the child’s residency, financial status, student status or marital status. An adult child under age 26 is
eligible for this extended coverage even if he or she is otherwise eligible for any employer-sponsored coverage. An adult child who is eligible for coverage
under this Plan both as an employee and as a dependent child can choose between coverage as an employee or as a dependent [Optional—or can be
covered both as an employee and as a dependent.]. The rule for coverage for step-children, foster children and grandchildren has not changed. See the
Summary Plan Description or the website for the current dependent coverage rules. Coverage is available for your unmarried step-children, foster children
and grandchildren living in a parent-child relationship with you (1) until age 19 if certain conditions are met; and (2) if a full-time student, from age 19 to 23,
if the child continues to be dependent upon you for support and maintenance and was covered under the Plan immediately prior to his or her 19th birthday.
Certification of school status on school letterhead must be provided. The rule for handicapped children has not changed. Coverage is available for your
handicapped child who is age 19 or older and who is dependent on you for support and incapable of supporting himself and became handicapped prior to
the limiting age stated above because of mental or physical handicap.
* Your Dependent SPOUSE, STEPCHILD, FOSTER CHILD, or GRANDCHILD must live in the same household in a common marital or parent/child relationship*
Relationship
Address: (Mark “X” if
Full Name
Specify if stepchild,
Sex
Social Security Number
Date of
Employed
Dependent resides with you,
(If Over Age
(First, MI, Last)
foster child or
Birth
otherwise you must include
grandchild
MM/DD/YY 19)
Dependent’s address.)
F M
YES NO
YES
YES
F M
F M
2.
Spouse Employer Information: *For spouses of participants hired on or after January 1, 2012, coverage is not available to working
spouses who are eligible for health care through their employer.*
Spouse’s Employer
Occupation:
Hire Date:
Termination Date (If Applicable):
Does spouse have medical coverage offered to him/her?
YES
NO
Is/Was spouse enrolled in employer medical coverage?
YES
NO
3.
NO
NO
Spouse’s Employer Address
Spouse’s Employer Phone Number
Please circle employment status:
Full Time
Part Time
Retired*
If YES-Please circle offered coverage:
If YES-Please circle type of policy:
Employee Only
Family
*Retirement Date _______________
Retired Disability: YES
NO
Medical
Employee/Spouse
Dental
Vision
RX
Employee/children
Dependent Children (Age 19 and older) Information
Dependent’s Name
Dependent’s Employer
Marital Status: Married Divorced Separated
Widowed Dependent’s Employer Address
Student Status:
Full Time
Part Time
Dependent’s Employer Phone Number
Occupation:
Please circle employment status:
Date of Hire:
Full Time
Part Time
*Retired - Retirement Date _____________________
Date of Termination (If Applicable):
Retired Disability:
YES
NO
Does dependent have medical coverage offered to him/herIf YES – Please circle offered coverage:
either through his/her own employer or spouse’s employer?
YES
NO
Medical
Dental
Vision
RX
Is/Was dependent enrolled in employer medical coverage?
If YES – Please circle type of policy:
YES
NO
Employee Only
Family
Employee/Spouse
Employee/Children
**IF YOU HAVE ADDITIONAL DEPENDENTS, PLEASE ATTACH A SEPARATE LISTING AND INCLUDE THE SAME INFORMATION AS REQUESTED ABOVE**
4.
•
Previous and/or Other Health and/or Medicare Information: *** PLEASE READ AND COMPLETE THIS SECTION THOROUGHLY***
If you, your spouse or any other dependent children have other medical coverage, you MUST complete this section and provide the requested
information.
• If your coverage is terminated, please state reason:__________________________________________________________________________
Covered Individual’s
Policy Holder Name
Name of Insurance
Insurance Company
Effective
Termination
Renewal
Name(s)
Company or Plan
Policy/ID#
Date
Date
Date
Enrollee’s Name
IF YOU OR A DEPENDENT ARE ELIGIBLE TO ENROLL IN MEDICARE, PLEASE COMPLETE THE FOLLOWING:
REASON FOR MEDICARE ENTITLEMENT (PLEASE MARK ONLY ONE)
Medicare No.
Age Disability
End Stage Renal
ESRD and
Indicate all Medicare Coverage that applies(HICN)
Disease(ESRD)
Disability
Part A, Part B and Part D & Effective Date
2
5.
Statement of Understanding
I understand that by signing below, I am agreeing to the following:
•
•
•
•
I agree to notify the Fund office of any changes in my marital status, and any change in the eligibility of my dependents.
I understand that any willfully false statement on this form can affect future coverage through the Plan. If fraudulent misstatements were
made, or if I fail to provide notice of any change in status as described above, the Fund has the right to recover from me any amounts it
should not have paid and legal action may be taken at any time.
I understand this election will remain in effect until the effective date of next open enrollment (or until I properly change my election, if
earlier). Further, by signing this form, I elect to pay my weekly contribution and authorize my employer to deduct the amount elected above
on a pre-tax basis through my employer’s cafeteria plan. I understand the payroll deduction must remain in effect for the full coverage year
and I will only be able to make changes as permitted in my employer’s cafeteria plan and as set forth in the attached Notice of Special
Enrollment Rights.
I affirm that I have reviewed all answers on this application and I verify that the answers are true, correct and complete to the best of my
knowledge.
________________________________________________
______________
Employee Signature
Date
COVERAGE ELECTION-PLAN 1000
****Please complete the following to choose your coverage election****
You may also log onto WWW.UFCWL400HEALTHANDWELFARE.ORG to make your enrollment election via the Plan’s
secure Online Enrollment system.
I understand that if I do not enroll myself and/or my dependent(s) in the United Food and Commercial
Workers Local 400 and Employers Health and Welfare Fund at this time, I will not be able to enroll myself
or the dependent that I failed to enroll until the next open enrollment period (Fall of 2015, for coverage
effective as of January 1, 2016), unless I experience a special enrollment event, as explained in the
enclosed Notice of Special Enrollment Rights.
PAYMENT TIER
TYPE OF COVERAGE
WEEKLY PAYROLL DEDUCTION
Employee Only
Employee and Child(ren)
Employee and Spouse
Family - Employee, Spouse, Child(ren)
Working Spouse –**ONLY APPLIES TO PLAN
1 AND PLAN 500 ELIGIBLES WHO ENROLL
IN PLAN 1000 INSTEAD** (applies when
spouse rejects their own employer
coverage)
$ 6.00
$12.00
$14.00
$16.00
$45.00 plus amount from Employee Coverage
Under the Plan rules, if your spouse is employed
and his/her employer offers health coverage, your
spouse must elect that coverage and the Plan will
coordinate for secondary benefits. If an Employee
enrolls his or her spouse for primary coverage
under the Plan and the spouse has coverage
available through his or her employment but
elects NOT to enroll in his or her provided plan, a
working spouse payroll deduction is required
from the Employee. To avoid this deduction, an
Employee’s spouse must be enrolled in his or her
employer’s plan. (The Plan pays as secondary if
the spouse does not enroll in the employer’s plan
and no working spouse payment is elected by the
Employee.)
EX. – Employee and Spouse Coverage
Working Spouse
Weekly Payroll Deduction
$14.00
45.00
$59.00
EX. – Family Coverage
Working Spouse
Weekly Payroll Deduction
$16.00
45.00
$61.00
*For spouses of participants hired on or after
January 1, 2012, coverage is not available to working
spouses who are eligible for health care through
their employer.
PLEASE SELECT YOUR TYPE OF COVERAGE AND APPLICABLE WEEKLY PAYROLL DEDUCTION:
1.
2.
Employee Only: I elect employee coverage and, I authorize my employer to deduct $6.00 weekly from my
paycheck on a pre-tax basis.
Employee and Child(ren): I elect employee and child(ren) coverage for my child(ren) listed on the Open
3
Enrollment form, and I authorize my employer to deduct $12.00 weekly from my paycheck on a pre-tax basis.
Coverage of children:
Coverage is available for natural children, legally adopted children and children placed for adoption up
to age 26, regardless of the child’s residency, financial status, student status or marital status. An
adult child under age 26 is eligible for this extended coverage even if he or she is otherwise eligible for
any employer-sponsored coverage. However, an adult child who is eligible for coverage under this Plan
both as an employee and as a dependent child can choose between coverage as an employee or as a
dependent[Optional—or can be covered as an employee and as a dependent].
3.
•
The rule for coverage for step-children, foster children and grandchildren has not changed. See the
Summary Plan Description or the website for the current dependent coverage rules. Coverage is
available for your unmarried step-children, foster children and grandchildren living in a parent-child
relationship with you until (1) age 19 if certain conditions are met; and (2) if a full-time student, from
age 19 to 23, if the child continues to be dependent upon you for support and maintenance and was
covered under the Plan immediately prior to his or her 19th birthday. Certification of school status on
school letterhead must be provided.
•
The rule for handicapped children has not changed. Coverage is available for your handicapped child
who is age 19 or older and who is dependent on you for support and incapable of supporting himself
and became handicapped prior to the limiting age stated above because of mental or physical handicap.
Employee and Spouse: I elect coverage for myself and the spouse listed on the Open Enrollment form, and I
authorize my employer to deduct $14.00 weekly from my paycheck on a pre-tax basis. (See #5 below if
spouse is working). I understand spousal coverage is not available if I was hired on or after January 1, 2012
and my spouse is eligible for coverage through his/her employer.
Coverage for a dependent spouse:
•
A dependent spouse must be living with the employee in the same household and in a common marital
relationship.
4.
Family - Employee, Spouse and Child(ren): I elect coverage for myself, my spouse and Child(ren) listed on
the Open Enrollment form, and I authorize my employer to deduct $16.00 weekly from my paycheck on a pretax basis. (See #5 below if spouse is working). I understand spousal coverage is not available if I was hired on
or after January 1, 2012 and my spouse is eligible for coverage through his/her employer.
5.
Working Spouse Payment: I elect the working spouse option for my spouse listed on the Open Enrollment
form. By signing this form, I authorize my employer to deduct $45.00 per week from my paycheck for Primary
coverage on a pre-tax basis for my spouse. I understand this payroll deduction will remain in effect until my
spouse enrolls in his/her employer’s sponsored plan. I understand spousal coverage is not available if I was
hired on or after January 1, 2012 and my spouse is eligible for coverage through his/her employer.
Under the Plan rules, if your spouse is employed and his/her employer offers health coverage, your spouse
must elect that coverage and the Plan will coordinate for secondary benefits. If an Employee enrolls his/her
spouse for primary coverage under the Plan and the spouse has coverage available through his/her
employment but elects not to enroll in his/her employer-provided plan, a working spouse payroll deduction is
required from the Employee. The amount of this Working Spouse payroll deduction will be determined by the
collective bargaining agreement. If your spouse declines his/her employer sponsored coverage, you may elect
Primary coverage under the Plan by making the working spouse payment. The Plan pays as secondary if the
spouse does not enroll and no working spouse payment is elected by the Employee.
•
Employee Authorization: By signing below, I understand this election will remain in effect until the effective
date of next open enrollment (or until I properly change my election, if earlier). Further, by signing this form, I
elect to pay my weekly contribution and authorize my employer to deduct the amount elected above on a pretax basis through my employer’s cafeteria plan. I understand the payroll deduction must remain in effect for
the full coverage year and I will only be able to make changes as permitted in my employer’s cafeteria plan
and as set forth in the attached Notice of Special Enrollment Rights.
I hereby certify that the foregoing information on these pages is true, correct and complete to the best of my
knowledge and belief. I understand that any willfully false statement on this form can exclude me and my
dependents from future coverage through the Plan and can cause a loss of coverage retroactively.
_______________________________________________
EMPLOYEE NAME (PRINT)
___________________________________________
SOCIAL SECURITY NUMBER
_______________________________________________
EMPLOYEE SIGNATURE
_______________
DATE
_________________
STORE NUMBER
Please note that completion of this enrollment, election and payroll deduction authorization form is not a guarantee of eligibility for
benefits. For questions concerning eligibility, contact the Plan Office.
***PLEASE COMPLETE, SIGN AND RETURN TO THE FUND OFFICE AT THE ADDRESS OR FAX NUMBER BELOW ***
UFCW LOCAL 400 AND EMPLOYERS HEALTH AND WELFARE FUND
600 D STREET ∙ SUITE 250 ∙ SOUTH CHARLESTON, WV 25303
FAX: 304-345-2832
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