Check One Box: New Hire Changing Coverage Store Acquisition
2013 Guam Crew Insurance Form
Page 1 of 4
Check one box: New hire/ new enrollee Changing Coverage COVERAGE EFFECTIVE Date:______
Employee Information / Last First MiddleName: / EMPLOYEE #: ______
Your employee # can be found on the top right hand corner of your pay stub.
address: / home phone ( ) -
City: / State: / Zip code:
/ Please see Page 3for detailed instructions
Reason for Change / be specific when providing your reason for change below:
reason for change (see instruction sheet, page 3): ______Date of event: ______
Indicate your choices (Bi-weekly Premium Rates) / GUAM (medical) EMPLOYEE ONLY EMPLOYEE + SPOUSE EMPLOYEE + DOMESTIC PARTNER
EMPLOYEE + CHILD(REN) FAMILY FAMILY WITH DOMESTIC PARTNER
NetCare Insurance – Employee Only Medical (54GM) $35.37 Employee Only
NetCare Insurance –Dependent Medical (54GM) $129.58 Employee + Spouse or Domestic Partner
$113.88 Employee + Child(ren)
$253.96 Family or Family with Domestic Partner
DECLINE COVERAGE
GUAM (DENTAL) EMPLOYEE ONLY EMPLOYEE + SPOUSE EMPLOYEE + DOMESTIC PARTNER
EMPLOYEE + CHILD(REN) FAMILY FAMILY WITH DOMESTIC PARTNER
NetCare Insurance – Dental (54GD)$20.18 Employee Only$40.72 Employee + Spouse or Domestic Partner
$38.10 Employee + Child(ren)$56.04 Family or Family with Domestic Partner
DECLINE COVERAGE
Dependent Information / Please provide the following information on family members who are to be covered by your medical/dental plan: (see page 3 for list of eligible dependents)NEW for 2013. You must also sign and submit the SURCHARGE AFFIDAVIT form OR YOU WILL AUTOMATICALLY HAVE SURCHARGES ADDED TO YOUR PREMIUM. (Page 2)
for Medical/
Dental Plan / Dependent name
Last name, first name middle initial / SOCIAL SECURITY NUMBER / Date of Birth
mm/dd/yyyy / SPOUSE, domestic partner OR CHILD / male or female / Please indicate: Yes or No / If child age 26 or older:
Dental / Vision / Medical / Handicapped? Please indicate: Yes or No
Signature / I have reviewed the above insurance elections. Where I have not made an election or selected “decline coverage”, I have rejected coverage. I have until prior to the first day of the month that coverage could begin to make this election. After that date I understand that I will not be able to change the coverage elected or to enroll for any coverage until McDonald’s next Annual Enrollment period or within 31 days (60 days if the special event relates to CHIP or Medicaid coverage) of a qualifying life event change. At that time acceptance of the requested insurance change may depend on acceptance by an HMO/Dental HMO (DHMO). If applicable, I certify that this request is consistent with my life event change. I understand that I am responsible for paying each premium for the HMO/DHMO coverage I elect. I elect to pay my premiums, by payroll deductions under the McDonald’s premium payment plan for coverage that I elect. Failure to do so may result in termination of my coverage. I understand that, unless I change my election for a future year or because of a life event change, my insurance election on this form will remain in effect from year to year at the employee premium amounts announced by McDonald’s in the future.
Employee Signature: / Date:
Please forward this completed form and all required attachments (if applicable) to:FORM 3837A 11/1/12
Hawaii Human Resources Department
2013 Guam Crew Insurance Form
Page 1 of 4
To make an insurance change based on a qualifying life event, you must notify the McDonald’s Service Center by completing the attached election form within 31 days (60 days if the special event relates to CHIP or Medicaid coverage) of your qualifying life event date. If it is past that date, changes cannot be processed.
SURCHARGE AFFIDAVITS for Annual enrollment
Employee Information / Last First MiddleName: / Employee #: ______
**Your employee # can be found on the top right corner of your pay stub
Tobacco use
Complete only if ee elects medical coverage
TOBACCO USE AFFIDAVITBeginning in 2013, a tobacco use surcharge is being added to the medical premium for tobacco users. Complete the affidavit below to certify whether or not the surcharge should apply to you. IF YOU DO NOT COMPLETE THE AFFIDAVIT AND FINISH YOUR ANNUAL ENROLLMENT, YOU WILL AUTOMATICALLY PAY THE SURCHARGE if you’re enrolled in a McDonald’s medical plan for 2013. You will not be able to change this surcharge until annual enrollment for 2014.
Remember, use of a tobacco product means any use (even one time) of a tobacco product, including cigarettes, chewing tobacco, cigars, pipes or any other product that contains tobacco.
---- CERTIFICATION ------
By checking a box below, I agree that the statement I check is true and accurate to the best of my knowledge. I understand that if I am being purposefully dishonest, I could be subject to one or more of the following actions: I may be required to pay the surcharge for any months of the year that I didn’t pay it; my coverage may be terminated back to January 1, and I may be required to pay back all amounts that were paid from the medical plan on my behalf; and I may be subject to disciplinary action up to and including termination of my employment.
I certify …
I and all of my covered dependents have not used any tobacco products during the past 90 days or more, orhave completed the medical plan’s smoking cessation program since August 1, 2012. (Surcharge does not apply.)
OR
I or at least one of my covered dependents have used a tobacco product within the past 90 days and have not completed the medical plan’s smoking cessation program since August 1, 2012. (Surcharge applies.)
Spouse coverage
Complete only if medical coverage category is ee+ spouse or DP, or family with spouse or DP
Click here if you are not covering a SP or DP
AFFIDAVIT REGARDING SPOUSE ACCESS TO OTHER COVERAGEBeginning in 2013, a spousal surcharge is being added to the medical plan premium for employees whose covered spouse or domestic partner also has access to comprehensive medical coverage through his or her employer (other than McDonald’s). IF YOU DO NOT COMPLETE THE AFFIDAVIT AND FINISH YOUR ANNUAL ENROLLMENT, YOU WILL AUTOMATICALLY PAY THE SURCHARGE if you cover a spouse or domestic partner on your McDonald’s medical plan for 2013.Remember, comprehensive coverage means the insurance covers a wide variety of health care services (including doctor visits, hospital stays, surgery and rehabilitation) and has no lifetime dollar benefit limit, and has an annual dollar benefit limit of $2 million or more. Limited benefit plans and Medicare are not considered comprehensive coverage.
---- CERTIFICATION ------
By checking a box below, I agree that the statement I check is true and accurate to the best of my knowledge. I understand that if I am being purposefully dishonest, I could be subject to one or more of the following actions: I may be required to pay the surcharge for any months of the year that I didn’t pay it; my coverage may be terminated back to January 1, and I may be required to pay back all amounts that were paid from the medical plan on my behalf; and I may be subject to disciplinary action up to and including termination of my employment.
I certify …
My covered spouse or domestic partner does not have access to comprehensive medical coverage through his or her employer (or he/she is a McDonald’s staff or McOpCo restaurant employee). (No surcharge.)
OR
My covered spouse or domestic partner has access to comprehensive medical coverage through his or her employer (other than McDonald’s). (Surcharge applies.)
Surcharge Add from Mailer
What’s the extra cost?The add-on premium cost is the same for tobacco use and spouse/domestic partner coverage. If both add-ons apply to you (you and/or a covered family member use tobacco and you cover a spouse/domestic partner who has access to another employer’s coverage), then the extra cost you pay each month is two times the number below.
For 2013, the surcharge for McDonalds PPOs and HMOs is:
$33 per month for Restaurant employees and Staff in the Associate and Coordination bands
$45 per month for Staff above the Coordination band
$58 per month for Officers
Take note: The add-on cost is only applied once for tobacco use, regardless of how many family members use tobacco.
Reason for Change Instruction Sheet
Detailed Instructions /- You may take medical under one carrier and dental under another carrier.
- All Medical/Dental premiums are bi-weekly. If you are paid weekly, divide by 2.
- Premiums are pre-tax unless you have domestic partner coverage. See important domestic partner information in the dependents section on page 2.
- If you elect any coverage other than employee only, complete the Dependent Information section below.
- A qualifying life event change allows you to request a change in your current medical/dental coverage category (i.e., Employee + Spouse, Family) within 31 days (60 days if the special event relates to CHIP or Medicaid coverage) of the event.
Life Event Changes / Note: Because pre-tax dollars are used for Plan contributions, the IRS requires that changes in elections for these contributions be made only on an annual basis (effective January 1st) unless you have one of the following qualifying life event changes:
- Marriage, divorce, or annulment.* (Submit first and last page of divorce decree along with this application.)
- Death of Spouse or Dependent.*
- Birth, adoption, or placement for adoption of a Dependent.*
- Beginning or termination of employment for you, your spouse or your Dependent.*
- Change in employment-related eligibility for the Plan or another health plan, by you, your spouse or Dependent.*
- Change in eligibility status of your spouse or your Dependent under the Plan or another healthplan.*
- Beginning or returning from an unpaid leave of absence by you, your spouse or Dependent (subject to the “Unpaid Leave" rules).*
- Strike or lockout involving you, your spouse or your Dependent.*
- You, your spouse or your Dependent becomes entitled to Medicare, Medicaid or the Child Health Insurance Program(CHIP).
- Your Dependent’s coverage under a Qualified Medical Child Support Order.
- Loss of coverage under another health plan that qualifies you or your Dependents for special enrollment under the Plan or another health plan.
- Certain significant increases or decreases in cost of a health, vision supplement or dental option under the Plan, as determined by the Plan Administrator.
- Significant decrease in coverage provided under a health, vision supplement or dental option under the Plan, as determined by the Plan Administrator.
- Your change in residence due to a job transfer that is at least 30 miles from your previous job location, if the change in location causes you to lose coverage under an HMO under the Plan.
- Change in election under your spouse’s or Dependent’s medical, dental or vision supplement plan if that change is allowed under the IRS rules or that plan has a different enrollment period and the change in election under this Plan is consistent with and corresponds to the change in election under the other plan.
The life event changes also apply to your domestic partner.
Dependents / Your eligible Dependents under the McDonald’s Plans (HMO/DHMO eligibility may differ) are:
- Your Spouse or Domestic Partner. * (with signed Affidavit of Domestic Partnership/Dependent Tax Certification (form 3838) after meeting domestic partner eligibility criteria). Do not list Domestic Partners as Spouses. Fiancées are not eligible.
- Children: Your child under age 26 (older if handicapped and dependent on you for support) who is your natural child, adopted child, step child, foster child, or a child for whom you are the legal guardian. Children or dependents, such as grandchildren or parents, should not be listed even if they are your IRS dependents, except in the case of children for whom you are the legal guardian. These same rules apply for the child(ren) of your spouse or domestic partner. *
- If your dependent information changes at any time in the future, go online or call the Service Center to update it.
- Proof includes one of the following:
*If you have domestic partner coverage, premiums for your domestic partner and all other family members are deducted from your pay on an after tax basis and you pay tax on the value of the Company’s contribution for that coverage, unless you certify that your family members are your dependents for federal income tax purposes. To make sure your domestic partner is covered and that you get appropriate tax treatment for your family’s premium, you must complete the “Affidavit of Domestic Partnership/Dependent Tax Certification” (form 3838).
When Coverage Begins / New Hires/Newly Benefit Eligible Employee’s:
- Your Employee coverage starts on the first day of the month following the end of your waiting period (refer to Summary Plan Description), assuming you have enrolled for that coverage prior to that date.
- The date you become covered, or
- The first day of the following month, unless you enroll the Dependent on the first day of the month in which you acquire the Dependent.
(Must elect coverage within 31 days (60 days if the special event relates to CHIP or Medicaid coverage) of a special event; refer to Summary Plan Description.
As a general rule: coverage begins the first of the month following the event except:
- For marriage, not later than the first day of the month following the event or
- For a dependent’s birth, as of the date of birth; or
- For adoption or placement for adoption, the date of the adoption or placement for adoption.
Please forward this completed form and all required attachments (if applicable) to:FORM 3837A 11/1/12
Hawaii Human Resources Department
2013 Hawaii/Guam Crew Insurance Form
Page 1 of 5
NOTE:
If required documentation is not provided, coverage will terminate, but premium amount will remain the same until you make changes at the next annual enrollment or next life event, whichever is earlier. If your dependents are dropped due to non-certification, they will not be eligible for COBRA benefits.
Please forward this completed form and all required attachments (if applicable) to:FORM 3837A 11/1/12
Hawaii Human Resources Department