Insurance Enrollment/Waiver
Please use all caps when completing the form
Form Reason
Annual Open Enrollment
Newly Eligible
Qualifying Event
Full Legal Name
*
First Name
Middle Name
Last Name
Gender
*
Male
Female
Date Of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
*
Single
Married
Do you have any children under 27 years of age?
*
Yes
No
Email
*
example@example.com
Social Security Number
*
Phone Number
*
Location
*
Eskimo Joe's
Eskimo Joe's Clothes
Mexico Joe's
EJPPG
Stan Clark Companies
EJ Supervisor
Whitney Bruning
Alyssa Dady
Lance Graves
Tim Holland
Dylan Kuzmic
Lindsey Oldham
Zach Tull
Hunter Whitford
Robert Williams
MJ Supervisor
Mason Bookout
Casey Billingsley
Kendall Brown
Sarah Gooden
Taylor Mowry
Robert Williams
PPG Supervisor
Kelly Allen
Steve Allison
Bill Allsup
John Killam
Taylor Lovekamp
Amy McCray
Michelle Rader
Chad Reed
Brittney Stokes
SCC Supervisor
Kendra Burtrum
Jordan Carris
Stan Clark
Melissa Hall
John Killam
Launa Miller
Robert Williams
JC Supervisor
Amber Bradley
Scott Brien
Laura Demaree
John Killam
Jennifer Miller
Terri Moorman
Health Insurance
Election/Waiver of Health Insurance
*
$1,000 Deductible Plan
$2,000 Deductible Plan
$4,000 Deductible Plan
High Deductible Health Plan (HSA Plan)
Waive Coverage
Level of Coverage - Health Plan
Employee Only
Employee + Spouse
Employee + Child(ren)
Family
Dental Insurance
Dental Election
*
$3,000 Plan with Ortho for children
$1,000 Plan with No Ortho
Waive Dental Coverage
Dental Level of Coverage
Employee Only
Employee + Spouse
Employee + Child(ren)
Family
Vision Insurance
Vision Election
*
Elect Vision Coverage
Waive Vision Coverage
Vision Level of Coverage
Employee Only
Employee + Spouse
Employee + Child(ren)
Family
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Next
Spouse's Name
First Name
Middle Name
Last Name
Spouse's Date of Birth
-
Month
-
Day
Year
Date
Spouse's Social Security Number
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Child #1 Name
First Name
Last Name
Child #1 Date of Birth
-
Month
-
Day
Year
Date
Child #1 Social Security Number
Child #1 Gender
Male
Female
Child #2 Name
First Name
Last Name
Child # 2 Date of Birth
-
Month
-
Day
Year
Date
Child #2 Social Security Number
Child #2 Gender
Male
Female
Child #3 Name
First Name
Last Name
Child #3 Date of Birth
-
Month
-
Day
Year
Date
Child #3 Social Security Number
Child #3 Gender
Male
Female
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Flexible Spending / Dependent Care Account
Flexible Spending Account
*
I want to contribute to the Flexible Spending Account
I want to contribute to the Dependent Care Account
I want my premiums to be withheld pre-tax, but I do not want to contribute to the Flexible Spending or Dependent Account
I decline to participate in the Flexible Spending or Dependent Care Account
Flex Savings Account Amount (Annual Amount)
Please indicate the annual amount you want to contribute in the FSA. The maximum amount is $2,850. The year runs 9/1-8/31. Note - this election may not be changed without a qualifying event. By electing the FSA you understand that pre-tax deductions will be made from your paycheck in equal amounts per pay period.
Dependent Care Amount (Annual)
Please indicate the annual amount you want to contribute in the Dependent Care Account. The maximum is $2,500 ($5,000 for Married filing jointly). This is to pay for childcare while you are at work. Please consult your Accountant as you cannot participate in BOTH the Dependent Care Account and take the Childcare Tax credit when your file your taxes at year-end.
HSA Contribution Amount (Annual)
Please enter the amount you want to contribute to the Health Savings Plan (HSA) for the year. We will divide this amount by 26. If you don't want to contribute any, enter $0.00. IRS Limit is $3,650 individual, $7,300 Family. Over 55 can elect an additional $1,000.
Limited FSA
If you wish to add funds into the Limited FSA for Dental and Vision. Please enter the annual amount here. The limit is $2,850.
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Supplemental Policies
Accident Insurance
*
Employee Only
Employee + Spouse
Employee + Child(ren)
Family
Waive Coverage
Critical Illness Insurance
*
Employee Only
Employee + Spouse
Employee + Child(ren)
Family
Waive Coverage
Employee Critical Illness Amount
Please Select
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
Spouse Critical Illness Amount
Please Select
Waive
$2,500
$5,000
$7,500
$10,000
$12,500
$15,000
$17,500
$20,000
$22,500
$25,000
Can't be more than 1/2 of Employee Election
Child's Critical Illness Amount
Please Select
Waive
$2,500
$5,000
Note it is the same per child
Have you used tobacco in the past 12 months?
Yes
No
Has your spouse used tobacco in the past 12 months?
Yes
No
Cancer Insurance
*
Employee Only
Employee + Spouse
Employee + Child(ren)
Family
Waive Coverage
Cancer Level
Level 1 - Low Option
Level 2 - High Option
You must complete the Supplemental Insurance Application to enroll in the Accident, Cancer or Critical Illness. Please click here to have that form emailed to you of this is your first time to enroll in one of these plans.
Please email me the Supplemental Insurance Forms
I am currently enrolled, so I do NOT need the forms
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Life Insurance
If you elected to purchase health insurance - $25,000 Worth of Life Insurance and AD&D Insurance is bundled with your health insurance. Do you want to purchase additional life insurance?
*
No additional life insurance
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
Other
Dependent Life Insurance - Spouse
No Additional Life - Spouse
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
Other
Dependent Life Insurance - Child(ren)
N/A - No dependent Children
Waive - Dependent life - Child
$2,500
$5,000
$7,500
$10,000
Short-Term Disability
*
This is included already as I am purchasing Health Insurance
I am not purchasing health insurance, but want to purchase Short-Term Disability Insurance
Waive Short Term Disability Coverage
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Life Insurance Beneficiary #1
First Name
Middle Name
Last Name
Beneficiary #1 -Relationship
Beneficiary #1 -Social Security Number
Beneficiary #1 - Date of Birth
-
Month
-
Day
Year
Date
% of benefit to Beneficiary #1
You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
Life Insurance Beneficiary #2
First Name
Middle Name
Last Name
Beneficiary #2 -Relationship
Beneficiary #2 -Social Security Number
Beneficiary #2 - Date of Birth
-
Month
-
Day
Year
Date
% of benefit to Beneficiary #2
You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
Life Insurance Beneficiary #3
First Name
Middle Name
Last Name
Beneficiary #3 -Relationship
Beneficiary #3 -Social Security Number
Beneficiary #3 - Date of Birth
-
Month
-
Day
Year
Date
% of benefit to Beneficiary #3
You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
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Next
Do you wish to name contingent beneficiaries?
Yes
No
Contingent Life Insurance Beneficiary #1
First Name
Middle Name
Last Name
Contingent Beneficiary #1 -Relationship
Contingent Beneficiary #1 -Social Security Number
Contingent Beneficiary #1 - Date of Birth
-
Month
-
Day
Year
Date
% of benefit to Contingent Beneficiary #1
You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
Contingent Life Insurance Beneficiary #2
First Name
Middle Name
Last Name
Contingent Beneficiary #2 -Relationship
Contingent Beneficiary #2 -Social Security Number
Contingent Beneficiary #2 - Date of Birth
-
Month
-
Day
Year
Date
% of benefit to Contingent Beneficiary #2
You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
Contingent Life Insurance Beneficiary #3
First Name
Middle Name
Last Name
Contingent Beneficiary #3 -Relationship
Contingent Beneficiary #3 -Social Security Number
Contingent Beneficiary #3 - Date of Birth
-
Month
-
Day
Year
Date
% of benefit to Contingent Beneficiary #3
You may divide the funds to go to multiple people. Just enter the percentage and make sure it totals 100%
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Pet Insurance
Pet Insurance Election
*
Elect Pet Insurance - I understand that I must contact Nationwide directly to enroll or cancel this benefit
Decline Pet Insurance
Norton LifeLock
Lifelock Election
*
Employee Only
Family
Waive Coverage
Lifelock Plan Coverage
Essential
Premier
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Next
I have been notified of my opportunity to purchase the above reference insurance. I understand that if I decline at this time for any of these coverages, that I will be unable to enroll later without a qualifying event (i.e. marriage, the birth of a child, etc.) until open enrollment in August 2023. In addition, my coverage elections on this form cannot be revoked or modified during the year unless I have a qualifying change in status as defined by the IRS.
*
Clear
Reason you are waiving coverage
Other Coverage
Medicare
Sooner Care
Indian Health Services
Other
If I elected any coverage and my paycheck is not sufficient to cover my premiums, I agree to pay SCC Accounting before the next Friday. I further understand that failure to pay my insurance premium will result in my coverage being terminated.
*
Clear
I certify by my signature below that I have completed this form to the best of my knowledge, and I agree to all the above statements.I hereby agree to have the above-elected contributions withheld from my paycheck. I give permission to the health plan I select to obtain and/or examine my medical records (and/or those of my dependent(s)) from any health care practitioner or institution in which care is provided while a member, to the extent permitted by law, and I understand the benefits and agree to the provisions as described in the Plan document.
*
Clear
Today's Date
*
-
Month
-
Day
Year
Date
MelissaEmail
example@example.com
Response
Submit
Should be Empty: