2024-2025 PLAZA RADIOLOGY OPEN ENROLLMENT FORM

PLAZA RADIOLOGY OPEN ENROLLMENT FORM - New Hire
ENROLLMENT INFORMATION:
Employer: Plaza Radiology
Hire Date

MonthDayYear
Date
Employee: (Please Complete all Sections Below)
Name

First NameMiddle NameLast Name
SSN
Home Telephone
Format: (000) 000-0000.
Gender

MaleFemale
Marital Status
Birth Date

MonthDayYear
Date
Address

Home Address

Street Address Line 2

CityState

Zip Code
Name (Last, First, MI)
SSN
Birth Date (mm/dd/yyyy)
Gender

MaleFemale
Select Coverage

MedDenVis
Name (Last, First, MI)
SSN
Birth Date (mm/dd/yyy)
Gender

MaleFemale
Select Coverage

MedDenVis
Name (Last, First, MI)
Relationship
SSN
Birth Date (mm/dd/yyy)
Gender

MaleFemale
Select Coverage

MedDenVis
Name (Last, First, MI)
Relationship
SSN
Birth Date (mm/dd/yyyy)
Gender

MaleFemale
Select Coverage

MedDenVis
Name (Last, First, MI)
Relationship
SSN
Birth Date (mm/dd/yyy)
Gender

MaleFemale
Select Coverage

MedDenVis
Name (Last, First, MI)
Relationship
SSN
Birth Date (mm/dd/yyyy)
Gender

MaleFemale
Select Coverage

MedDenVis
Coverage Elections

Coverage through BlueCross Blue Shield of TN
Medical - Choose One (Bi-Weekly Deduction)

Employee Only Option 1 - $53.81Employee Only Option 2 - $130.70Family Option 1 - $153.90Family Option 2 - $376.81
Declining Coverage

I am waiving Medical Coverage.
Health Savings Account (HSA)

Coverage through First Volunteer Bank
Annual Limits: Single $3,600 & Family $7,200; Catch-up Age 55+ $1,000
Only if electing Option 1 - HDHP

Yes, I am eligible for an HSA
I would also like to establish payroll deductions in the amount of (Enter total in the next box)

Select if adding additional amount to HSA bi-weekly
I would also like to establish payroll deductions in the amount of
I will be age 55 in 2022 and elect to exercise the catch-up contribution of (Enter total in the next box)

Select if you are contributing to this option
I will be age 55 in 2022 and elect to exercise the catch-up contribution of
If you do not have an existing HSA account with First Volunteer Bank you must go to the bank and set up before payroll deductions will begin
Declining HSA

I am waiving an HSA Account or am not eligible
Dental

Coverage through BlueCross BlueShield of TN
Bi-weekly Deduction

Employee Only - $17.64Family - $52.97
Declining Dental Coverage

I am waiving Dental Coverage.
Vision

Coverage through BlueCross BlueShield
Bi-weekly Deduction

Employee Only - $2.78Family - $7.22
Declining Vision Coverage

I am waiving Vision Coverage.
Authorization:
By signing below, I understand the coverage I have elected and/or waived above is effective September 1, 2022, and will remain effective until August 31, 2023, unless I have a qualifying event. If I do experience a qualifying event (or life event change), I further acknowledge that I have 30 days to notify Human Resources of this change.

I agree to be governed by the terms and conditions of the plans in which I have enrolled, and I acknowledge receipt of the employee notification documents. I authorize Plaza Radiology to deduct contributions from my earnings now or in the future as required under each of the plans. I also understand that if my paycheck is not sufficient to cover my contributions, Plaza Radiology may, in its sole discretion, automatically collect any such payment(s) from future paycheck(s I am also aware that it is my responsibility to notify my manager or supervisor of any future change in address that should occur through the course of my enrollment.
Employee’s Signature
Date

MonthDayYear
Date
Should be Empty:

PLAZA RADIOLOGY OPEN ENROLLMENT FORM - New Hire

ENROLLMENT INFORMATION:

Employer: Plaza Radiology

Coverage Elections

Health Savings Account (HSA)

If you do not have an existing HSA account with First Volunteer Bank you must go to the bank and set up before payroll deductions will begin

Dental

Vision

Authorization: