Section 1: Please Print or Type. Use Black Ink.
Employer Name / Social Security Number / Last Name / First name / MI
ABC Home & Commercial Services
Mailing Address / City / State / Zip Code
Business Phone / Home Phone / Email Address / Job Title / Effective Date
Date of Birth / Gender / Marital Status / Date of Hire / Salary
Male Female / Single Married Divorced Widowed
Enrollment Reason
Open Enrollment Change Enrollment New Hire Rehire Return from Active Duty Return from Leave of Absence Loss of Coverage
The below rates are deducted per pay period.
SectSection 2: Check the coverage level below and elect the appropriate level of coverage for you and/or your dependents
Group Pension Administrators – Employees paid 1st & 15th / Cost Per
Pay Period / Group Pension Administrators – Lawn Maintenance / Service / Cost Per
Pay Period
Employee Only / $ / Employee Only / $
Employee + Spouse / $ / Employee + Spouse / $
Employee + Child(ren) / $ / Employee + Child(ren) / $
Employee + Family / $ / Employee + Family / $
Aetna Voluntary Dental DHMO PDN
Employees paid 1st & 15th / Cost Per
Pay Period / Aetna Voluntary Dental DHMO PDN
Lawn Maintenance / Service / Cost Per
Pay Period
Employee Only / $14.71 / Employee Only / $6.79
Employee + Spouse / $29.07 / Employee + Spouse / $13.42
Employee + Child(ren) / $34.08 / Employee + Child(ren) / $15.73
Employee + Family / $48.44 / Employee + Family / $22.36
Davis Vision – Employees paid 1st & 15th / Cost Per
Pay Period / Davis Vision – Lawn Maintenance / Service / Cost Per
Pay Period
Employee Only / $3.89 / Employee Only / $1.79
Employee + Spouse / $7.00 / Employee + Spouse / $3.23
Employee + Child(ren) / $7.39 / Employee + Child(ren) / $3.41
Employee + Family / $11.67 / Employee + Family / $5.38
Section 3: Dependent Information (insert additional sheet if needed for dependents)
Last Name / First Name / MI / Check all applicable / Date of Birth / Social Security Number / Gender / Relationship / DHMO PCD ID Number
MEDICAL
DENTAL
VISION / M
F / Spouse
Last Name / First Name / MI / Check all applicable / Date of Birth / Social Security # / Gender
MEDICAL
DENTAL
VISION / M
F / Child
Last Name / First Name / MI / Check all applicable / Date of Birth / Social Security # / Gender / Relationship
MEDICAL
DENTAL
VISION / M
F / Child
Last Name / First Name / MI / Check all applicable / Date of Birth / Social Security # / Gender / Relationship
MEDICAL
DENTAL
VISION / M
F / Child
Section 3: If you or your spouse or dependents are refusing coverage, please complete below and sign the bottom of this application
I decline Medical coverage for: Myself My Spouse My dependent Children
Reason: ______; If other coverage please provide:
Carrier Name ______
Policy Number ______Coverage Dates ______/ I decline Dental coverage for: Myself My Spouse My dependent Children
Reason: ______; If other coverage please provide:
Carrier Name ______
Policy Number ______Coverage Dates ______
Section 4: Prior Coverage (please include copy of HIPAA Cert)
Within the past 12 months, have you or any of your covered dependents had any other individual or other group or individual Medical coverage including Medicare?
No Yes If yes, please complete below.
Carrier Name______Policy Number ______
Coverage Type
Employee Only Employee/Spouse Employee/Child(ren) Employee / Family
Effective Date ______Term Date ______
Employee Medicare ID______Effective Date ______
Spouse Medicare ID______Effective Date______
Will you or any of your covered dependent have any other group or individual Dental coverage, including Medicare?
No Yes If yes, please complete below.
Carrier Name______Policy Number ______
Coverage Type
Employee Only Employee/Spouse Employee/Child(ren) Employee / Family
Effective Date______Term Date ______
Employee Medicare ID______Effective Date ______
Spouse Medicare ID______Effective Date ______
Section 5: Concurrent Coverage
Will you or any of your covered dependent have any other group or individual Medical coverage, including Medicare in effect at the same time as this coverage?
No Yes If yes, please complete below.
Carrier Name______Policy Number ______
Coverage Type
Employee Only Employee/Spouse Employee/Child(ren) Employee / Family
Effective Date______Term Date ______
Employee Medicare ID______Effective Date ______
Spouse Medicare ID______Effective Date______
Will you or any of your covered dependent have any other group or individual Dental coverage, including Medicare in effect at the same time as this coverage?
No Yes If yes, please complete below.
Carrier Name______Policy Number ______
Coverage Type
Employee Only Employee/Spouse Employee/Child(ren) Employee / Family
Effective Date______Term Date ______
Employee Medicare ID______Effective Date ______
Spouse Medicare ID______Effective Date______
Section 6: Basic Life and AD&D – Employer Paid / Basic Life and AD&D (Officers) – Employer Paid
1 times annual salary not to exceed $150,000
Must be enrolled in the medical to receive the life benefit / $50,000 Benefit
Must be enrolled in the medical to receive the life benefit
Section 7: Voluntary Life and Voluntary AD&D Insurance
(Check with HR regarding dependent eligibility and Evidence of Insurability requirements for elections over the Guarantee Issue or late enrollment)
For Yourself: $10,000 increments, 4 times annual earnings not to exceed $500,000. Guarantee Issue $150,000
Elect Waive (V. Life)
Elect Waive (AD&D) / Amount of Coverage: $______
Amount of Coverage: $______/ Total Premium: $______
Total Premium: $______
Employees may be eligible to increase their own current Voluntary Life Amount during open enrollment up to $40,000 without completing the Statement of Health. If you wish to increase please contact Human Resources to complete the appropriate form & details regarding eligibility.
Dependent Voluntary Life election REQUIRES the Employee election
For Your Spouse: $5,000 increments, not to exceed 50% of the Employee election up to $150,000. Guarantee Issue $20,000.
Elect Waive / Amount of Coverage: $______/ Total Premium: $______/ Spouse Date of Birth
For Your Child(ren): $2,000 increments, not to exceed 50% of the Employee election up to $10,000
Elect Waive / Amount of Coverage: $______/ Total Premium: $______
Beneficiary (if listing a separate beneficiary for Voluntary Life, please add an additional page)
Primary – Full Name Address Social Security No. Relationship % of Benefit
Contingent – Full Name Address Social Security No. Relationship % of Benefit
If you are married, live in a community property state, and name someone other than your spouse as beneficiary, you may have your spouse sign below to waive his or her rights to any community property interest in the benefit.
As the Insured’s spouse, I do hereby consent to the beneficiary designations(s) indicated on this form and waive any rights that I may have to the proceeds of such insurance under applicable community property laws.
Print Spouse Name ______Signature of Spouse ______Date ______
I certify that I must satisfy the eligibility and actively at work requirements at my employer’s usual place of business on the date coverage for myself and any eligible dependents becomes effective. If I am not actively at work I understand that this coverage may not become effective until I return to work. I acknowledge that the coverage available to me has been explained by my employer and that I knowingly have elected to enroll and / or waive any of the above coverage’s. If I acquire a new dependent or involuntarily lose coverage, I acknowledge that I and my dependents may request enrollment in my employer’s benefit plan by applying within 30 days of the qualifying event. I understand that by declining, I may not enroll myself and / or dependents in my employer’s health plan until the next open enrollment or unless I experience a family status change. As a late applicant applying for coverage, I understand that proof of good health may be required for myself and eligible dependents. I understand, agree and represent that I have read this document or it has been read to me and that the answers provided within this entire application for coverage are to the best of my knowledge and belief, and are true and complete. I understand that if any intentional material false statement, misrepresentation or omission is contained here my coverage could be reduced, denied or voided. I understand the coverage does not become effective until my effective date or the renewal date of the plan(s).
Signature of the Employee: Date: