HEALTHCARE ENROLLMENT FORM

KLINGE OPEN ENROLLMENT FORM 2024

All information shared on this form is secure and private.
Employee Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Gender*
Marital Status*

SingleMarriedDivorcedWidow/widower
Social Security Number*
Primary Phone Number*
Email Address
Do you want to make a change to your benefits for January 1st, 2024?*

NoYes
What benefits do you want to change? (select all that apply)*

MedicalHSA ContributionDentalVision
MEDICAL INSURANCE & PRESCRIPTION
All medical contribution rates are per pay period*
IMPORTANT: The cancellation of Medical Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.
OTHER INSURANCE COVERAGE

Please provide your current medical insurance information below
Other Medical Insurance*

Insurance CarrierPolicy Number
HEALTH SAVINGS ACCOUNT (HSA)

For 2024, Klinge will contribute $1,500 if you enroll as an individual and $3,000 if you enroll with dependents. Contributions (50%) will be made every 6 months. The contributions will be prorated based on your date of hire.
Per Pay HSA Contribution (26 pays per year)
Please leave blank if you are not participating
For 2024, the maximum contribution amount for an individual is $4,150 and for a family is $8,300. Plus if you are age 55 or older, you can contribute an additional $1,000. These amounts include Klinge's contribution.
DENTAL INSURANCE
All dental contribution rates are per pay period*
IMPORTANT: The cancellation of Dental Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.
VISION INSURANCE
All vision contribution rates are per pay period*
IMPORTANT: The cancellation of Vision Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.
EMPLOYEE DEPENDENT & SPOUSE INFORMATION

(Medical, Dental and Vision)
Spouse Information

Click here if you are adding your spouse to your medical, dental or vision coverage for the 2024 plan year.
Child/Children Information

Click here if you are adding your child/children to your medical, dental or vision coverage for the 2024 plan year.
Spouse Information*
First Name, Last Name, Middle Initial
Spouse's Gender*
Spouse's Date of Birth*

MonthDayYear
Spouse's Social Security Number*
Enroll Spouse in (check all that apply)*

MedicalDentalVision
Please select the number of children who will be enrolled.*
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDentalVision
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDentalVision
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDentalVision
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDentalVision
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDentalVision
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDentalVision
VOLUNTARY LIFE AND AD&D INSURANCE

You can elect coverage for yourself, your spouse, and your children
Voluntary life insurance

Click here if you would like to enroll in Voluntary Life
Calculate the premium. First select your age bracket.
Type a question
Next, input your desired coverage amount.
$10,000 to $300,000 in $10,000 increments. Please note, amounts over $100,000 will require evidence of insurability to be completed.
This is your monthly premium.
Dependent Voluntary Life Insurance

Click here if you would like to enroll your spouse in Voluntary LifeClick here if you would like to enroll your child/children in Voluntary Life
Calculate the premium. First select your spouse's age bracket.
Spouse amount
Next, input the desired coverage amount for your spouse.
$5,000 to $150,000 in $5,000 increments. Please note, amounts over $25,000 will require evidence of insurability to be completed.
This is your spouse's monthly premium.
Input the desired coverage amount for your child(ren). Please include the total amount for all children.
Your child/children may receive a flat $10,000
This is your child's/children's monthly premium.
EMPLOYEE DEPENDENT & SPOUSE INFORMATION
Spouse's Name*

First NameLast Name
Spouse's Gender*
Spouse's Date of Birth*

MonthDayYear
Spouse's Social Security Number*
Please select the number of children who will be enrolled.*
1. Child's Information*

First NameLast Name
1. Child's Gender*
1. Child's Date of Birth*

MonthDayYear
1. Child's Social Security Number*
2. Child's Information*

First NameLast Name
2. Child's Gender*
2. Child's Date of Birth*

MonthDayYear
2. Child's Social Security Number*
3. Child's Information*

First NameLast Name
3. Child's Gender*
3. Child's Date of Birth*

MonthDayYear
3. Child's Social Security Number*
4. Child's Information*

First NameLast Name
4. Child's Gender*
4. Child's Date of Birth*

MonthDayYear
4. Child's Social Security Number*
5. Child's Information*

First NameLast Name
5. Child's Gender*
5. Child's Date of Birth*

MonthDayYear
5. Child's Social Security Number*
6. Child's Information*

First NameLast Name
6. Child's Gender*
6. Child's Date of Birth*

MonthDayYear
6. Child's Social Security Number*
AUTHORIZATION AND SIGNATURE

Sign & Date
- I understand that I cannot change any of these elections for medical, dental, and vision coverage until the next open enrollment period, unless I have a qualifying change in status.
- If I waived medical coverage, I certify that I have other medical coverage.
- Payroll Deduction/Pretax Premium/Billing Agreement: I authorize Klinge and all its affiliates to deduct from my earnings the amount required to cover my share of the premium for these coverages.
- If I elect to participate in pretax medical, dental, and vision premiums, I authorize Klinge and all its affiliates to reduce my taxable income by an amount equal to my medical, dental, and vision premiums.
- If I am being billed, I understand that failure to pay my premium(s) will result in cancellation of coverage.
- Waiver Agreement: After my initial enrollment period, I understand that in order to enroll in the future I may be required to provide evidence of insurability, and I may enroll in some plans only during open enrollment periods and/or be subject to pre-existing condition limitations.
- Release of Information: I understand that certain information collected by Klinge, including some collected using this form, must be sent to the carriers of the plans in which I have enrolled. Klinge and the insurance carriers will treat this information as confidential.
Please type your signature to indicate you have read the above.*
Employee Signature*
Date*

MonthDayYear
Date
Should be Empty:

KLINGE OPEN ENROLLMENT FORM 2024

MEDICAL INSURANCE & PRESCRIPTION

OTHER INSURANCE COVERAGE

HEALTH SAVINGS ACCOUNT (HSA)

DENTAL INSURANCE

VISION INSURANCE

EMPLOYEE DEPENDENT & SPOUSE INFORMATION

VOLUNTARY LIFE AND AD&D INSURANCE

EMPLOYEE DEPENDENT & SPOUSE INFORMATION

AUTHORIZATION AND SIGNATURE