HEALTH INSURANCE AUTHORIZATION FORM
PAYROLL DEDUCTION / WAIVER
FOR ALL FULL-TIME EMPLOYEES
PLEASE CHECK ONE MEDICAL OPTION BELOW:My choice for medical coverage is indicated below, and I authorize the applicable
BI-WEEKLY or MONTHLY payroll deduction for such coverage.
Individual Coverage Family Coverage
Tier 1: BCBS HMO Blue New England $10/25 plan:
(Bi-Weekly) $108.58 $284.82
(Monthly) $235.27 $617.11
Tier 2: BCBS HMO Blue New England/$1,000 deductible:
(Bi-Weekly) $90.84 $238.26
(Monthly) $196.81 $516.23
I am declining health insurance.
PLEASE CHECK ONE DENTAL OPTION BELOW:
My choice for dental coverage is indicated below, and I authorize the applicable
BI-WEEKLY or MONTHLY payroll deduction for such coverage.
Individual Coverage Family Coverage
Tier 1: Dental Blue $ 5,000 Limit w/ Orthodontics:
(Bi-Weekly) $7.98 $23.05
(Monthly) $17.19 $49.94
Tier 2: Dental Blue $1,500 Limit:
(Bi-Weekly) $6.14 $17.85
(Monthly) $13.31 $38.68
I am declining dental insurance.
No Coverage. I am declining all health & dental insurance.
Please note: Medical Deductions are automatically deducted on a pre-tax basis.
NOTICE OF SPECIAL ENROLLMENT RIGHTS: If you are declining enrollment for yourself or your dependents (including your spouse) because of other health 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.
Name: ______
Signature: Date:
2013 RATES 5.13