2005 Status Change Form

Family MedCenters, PA

Name ______Date ______

th, following 30 days of employment.

SS Number ______

QUALIFIED STATUS CHANGES
Only qualifying changes in status will be accepted as reason for change in benefits selection. All qualified changes must bereceived within 31 days of qualifying event. Indicated are the acceptable qualifying events below. Supporting documentation of the qualifying event may be required (i.e., birth certificate, marriage certificate, etc.)

Date of event/change: ______(Coverage will begin the first of the month following date of event/change)

(Please check one)

AdoptionSpouse’s change in employment status or health coverage

Birth by employer.

Death Change from: FT to PT

Divorce

MarriagePT to FT (Fill out a New Employee Benefit Enrollment

Form)

Changes to current coverage CURRENT COVERAGE

__ Drop coverage Coverage level (choose 1) __ No coverage Coverage Level

__ I elect Platinum coverage __ Employee __ Platinum __ Employee

__ I elect Gold coverage __ Employee + Spouse __ Gold __ Employee + Spouse

__ I elect Silver coverage __ Employee + Child(ren) __ Silver __ Employee + Child(ren)

__ I elect Bronze coverage __ Employee + Family __ Bronze __ Family

__ Drop coverage Coverage level (choose 1)__ No CoverageCoverage Level

__ I elect dental coverage __ Employee__ Employee

__ Employee + 1__ Employee + 1

__ Family __ Family

__ Drop coverage

__ I elect Voluntary Life Amount $ ______Current voluntary life insurance coverage:

May be purchased in $10,000 increments up to the lesser of

4 times your base salary or $500,000, when combined with

employer paid basic life. Proof of insurability may be required____ None $______

for late enrollees and/or amounts greater that $125,000.

______Drop coverage Current long term disability coverage:

___ I elect long term disability ____ None ____ Elected

__ Drop coverage __ Drop coverage

__ I elect Spouse Dep Life: __ I elect Child(ren) Dep Life::

__ $5,000 __ $2,000Current coverage on:

__ $10,000 __ $4,000

__ $15,000 __ $6,000

__ $20,000 __ $8,000Spouse $______

__ $25,000 __ $10,000 (max)

__ other ______other ______None elected

Both require election of voluntary life: Child(ren) $______

Spouse benefit cannot exceed ½ times the employee amount.

Child benefit cannot exceed spouse benefits. _____ None elected

Proof of insurability may be required for late enrollees and/or

amounts greater that $25,000.

__ Drop additional coverageCurrent additional AD&D coverage:

__ I elect Voluntary AD&D Amount $ ______

$ ______

May be purchased in $10,000 increments up to $500,000

when combined with employer paid benefit._____ No additional elected

_ ___ I wish to discontinue Health Care Reimbursement Current annual amount for:

___Change my annual amount to $ ______Health Care Reimbursement

(max. $2500.00 yr)

___ I wish to discontinue Dependent Care Reimbursement ___ None $______

___ Change my annual amount to $ ______Dep. Care Reimbursement:

(max. $5000.00 yr)

___ None $______

___ Please cancel my AFLAC / Willis policy. Current AFLAC / Willis policie(s)

___ Cancer Policy

___ Intensive Care Policy___ Cancer Policy

___ Accident Care Policy___ Intensive Care Policy

___ Short-term Disability ___ Accident Policy

___ Short-tem Disability

___ Please have an AFLAC rep. contact me.___ None

Dependent Information (to be added) (check coverage)

Name SSN Relationship DOB Medical Dental Life Ins.

Dependent Information (to be deleted)

Signature ______Date______