Health and Dental Insurance Payroll Deduction Authorization s1

HEALTH INSURANCE AUTHORIZATION FORM

PAYROLL DEDUCTION / WAIVER

FOR ALL FULL-TIME EMPLOYEES

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

Blue Cross Blue Shield-

HMO Blue New England (Bi-Weekly) $87.60 $229.78

(Monthly) $189.81 $497.86

I am declining health insurance.

DENTAL BLUE: (100/80, $25 deductible, $1500 limit)

Individual Coverage Family Coverage

(Bi-Weekly) $5.90 $15.96

(Monthly) $12.77 $34.58

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:

PLEASE RETURN COMPLETED FORM TO IVETTE M. ARIAS IN BVARI’S HUMAN RESOURCES DEPARTMENT (Mail Stop 151B-JP, or Deliver to Room 11B-60) BY MAY 29, 2008

2008 NEW RATES 4.18.08