ENROLLMENT FORM

ENROLLMENT FORM
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C. LIMITED BENEFIT PLAN SELECTION

You MUST enroll in the Fixed Indemnity Medical Insurance Plan before adding any additional benefits in Section C. Your coverage level for the additional benefits in Section C will be identical to your fixed indemnity medical plan selection. These plans are underwritten by BCS Insurance Company and 4 Ever Life Insurance Company
Type a question

NO to ALL BenefitsEmployee Only: $19.98Employee + Child(ren): $33.17Employee + Spouse: $37.96Employee + Family: $50.55
Dental +$5.40 ($14.58, $10.80, $20.52)

Yes
Vision + $2.42 ($6.54, $4.84, $9.20)

Yes
Term Life +$.60 ($.9, $.9, $1.80)

Yes
Short-term Disability +$4.20

Yes
YOU MUST SIGN AND DATE EVEN IF YOU DECLINE COVERAGE

By signing below, I confirm I have read the Benefits Summary and the Limitations and Exclusions for the recommended benefit plans; I've been offered self-funded ACA compliant coverage (MEC Wellness/Preventive) and open enrollment is only available for a limited time. I also understand that making no benefit selection is a declination of benefit coverage and benefit coverage is only available to employees who are over the age of 18 with a valid SSN.
SIGNATURE*

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