Teammate ID # / Store # / Last 4 digits of SS#
XXX – XX - / Cell Phone:
Teammate’s Name: Last, First, MI
/ Gender:
Male ☐ Female ☐ / Status:
☐ Single ☐ Married / Date of Birth: / /
Teammate Mailing Address: Address, City, State, Zip Code / Email Address:
Step 1: Choose - MEDICAL/VISIONPLAN OPTIONS – See Benefits Guide for more details
Preferred Care Blue Core Plan
Coverage / Tobacco
Free User(s) / One
Tobacco User / Two
Tobacco User(s)
Teammate Only / ☐ $45 / ☐$75
Teammate + Child / ☐ $55 / ☐$85
Teammate + Spouse / ☐ $90 / ☐$120 / ☐$150
Family / ☐$100 / ☐$130 / ☐$160
Save an Additional $20 for Teammate Only Coverage and
$40 for Teammate + Spouse Coverage Weekly
See Benefits Guide- Page 10 / Blue Select Plus Narrow Network Plan
Coverage / Tobacco
Free User(s) / One
Tobacco User / Two
Tobacco User(s)
Teammate Only / ☐$35 / ☐$65
Teammate + Child / ☐$45 / ☐$75
Teammate + Spouse / ☐$75 / ☐ $105 / ☐ $135
Family / ☐$85 / ☐ $115 / ☐ $145
Save an Additional $20 for Teammate Only Coverage and
$40 for Teammate + Spouse Coverage Weekly
See Benefits Guide - Page 10
Step 2: Choose - CIGNA DENTAL PLAN (Optional and can be Purchased without Medical/Vision)
☐No, I want to decline coverage ☐ Teammate Only $2
☐ Teammate + Child $4 / ☐ Teammate + Spouse $4
☐ Family $6
Step 3 : SPOUSAL SURCHARGE
ONLY FOR SPOUSES EMPLOYED AND ELIGIBLE FOR BENEFITSand COVERED ON OUR PLAN
Is your Spouse employed and eligible for Health Benefits Coverage under his/her employer’s plan? ☐ Yes Add $50 ☐ No
**If “Yes” and you elect to cover your spouse who is eligible for his/her employer benefits, $50 weekly surcharge will be added
BENEFIT COST CALCULATOR
- Medical/Vision
- Dental
- Surcharge
Start Now Discount(s): / -$ / Deduct $20 for Teammate Coverage or $40Teammate + Spouse Coverage
Total Weekly Cost: / $ / (See Page 10 of Benefit Guide for Start Now Discount Requirements)
DECLINE BENEFITS - NO, I DO NOT WANT MEDICAL/VISON OR DENTAL COVERAGE AT THIS TIME
HIPAA Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (of if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). 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. However, you must request enrollment within 30 days of the event.
☐I have read the special HIPAA enrollment provision above and chose NOT to elect any medical or dental insurance for myself or my dependents at this time.
Teammate Signature Date
ACCEPT BENEFITS - YES, I WOULD LIKE MEDICAL/VISION AND LIFE INSURANCE
I hereby (1) request to enroll in the benefits for which I am or may become eligible as indicated on this enrollment card under the plan created by the Plan Sponsor; (2) reaffirm that I will abide by the provisions set forth in the Summary Plan Description and Plan Document; (3) authorize the required deductions form my earnings, understanding that an amount equal to the required contributions for the coverage I have elected under the Health Plan will be deducted from my payroll check on a pre-tax basis as provided by the provisions of the Plans Sponsor’s Flexible Benefit Cafeteria Plan; if I decide that I do not want this pre-tax treatment of my contributions, and instead, want to pay my portion of the Health Plan premiums on an after-tax basis, I must separately complete a Cafeteria Plan Election form waiving such pre-tax treatment; (4) designate the beneficiary named on this card to receive the benefits, if any, payable in the event of my death; and (5) certify that the dates of birth and other information indicated on this card are correct. I understand that this election of coverage cannot be changed until the next annual enrollment period unless I experience a qualifying event under the IRS Section 125, which would allow me to make changes consistent with such qualifying event.
Teammate Signature Date
INDIVIDUALS COVERED UNDER THIS PLAN (List Names of Spouse and Children under age of 26)
Who will have Coverage. Full Given Name(s): (Required) / Plans Enrolled / Relationship / SS # / Sex / Birth Date
1. / ☐Med/Vision ☐ Dental / M ☐ F☐
2. / ☐Med/Vision ☐ Dental / M ☐ F☐
3. / ☐Med/Vision ☐ Dental / M ☐ F☐
4. / ☐Med/Vision ☐ Dental / M ☐ F☐
5. / ☐Med/Vision ☐ Dental / M ☐ F☐
6. / ☐Med/Vision ☐ Dental / M ☐ F☐
LIFE INSURANCE – FREE - Coverage 1x Annual Salary ($10,000 minimum, $50,000 maximum)
** REQUIRED** If teammate enrolls in our Medical/Vision Plan, the Company automatically provides Life Insurance (See Benefit Plan Coverage)
Beneficiary(ies) Full Given Name(s): / Primary or Secondary / % / Relationship / Social Security # / Phone / Birth Date
1. / P ☐ S☐
2. / P ☐ S☐
3. / P ☐ S☐
OTHER COVERAGE
Are you covered under another group insurance plan? ☐Yes ☐No Medicare? ☐Yes ☐No Medicaid? ☐Yes ☐No
Are your dependentscovered under another group insurance plan?☐Yes ☐No Medicare? ☐Yes ☐No Medicaid? ☐Yes ☐No
TOBACCO USE STATEMENT
To declare you are tobacco-free means you do not use tobacco currently and have not used tobacco products (cigarettes, cigars, chewing tobacco, snuff) in any amount for a least the last 90 days.
- I have read the statement above and I confirm that I understand it.
- I certify that the answer provided below regarding my use or non-use of tobacco products is true and correct.
- I understand that my employment at Balls Food Stores may be terminated if I give a false answer.
- I also understand that it is my responsibility to notify Balls Foods Stores in writing if my tobacco-use status changes in the future.
Teammate: Spouse (if applicable):
I am Tobacco Free (Tobacco Free Rates Apply) Tobacco Free (Tobacco Free Rates Apply)
I am NOT Tobacco Free My Spouse is NOT Tobacco Free
Teammate Signature Printed Name
Rewards for participating in the Start Now Programs and the tobacco-free discount program are available to all eligible teammates. If you are unable to meet a standard for the incentive under this program, you might qualify for an opportunity to earn the same incentive by different means. To be considered for a different means of earning select incentives you must contact the Ball’s Foods Start Now Hotline at 913-321-3663 ext.3444 within 60 days of your insurance start date. We will work with you (and, if you wish, with your doctor) to find an alternative with the same incentive that is right for you in light of your health status.
FAX COMPLETED FORM TO 913-551-8504
OFFICE USE ONLYHire Date: / Effective Date:
□GRID / □BENEFIT FOCUS / □PAYROLL / □FILE