HEALTHCARE ENROLLMENT FORM

  • KLINGE OPEN ENROLLMENT FORM 2024

    All information shared on this form is secure and private.
  • Date of Birth*
     - -
  • Marital Status*
  • Do you want to make a change to your benefits for January 1st, 2024?*
  • What benefits do you want to change? (select all that apply)*

  • MEDICAL INSURANCE & PRESCRIPTION

  • 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

  • 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.

  • 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

  • IMPORTANT: The cancellation of Dental Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.

  • VISION INSURANCE

  • 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's Date of Birth*
     - -
  • Enroll Spouse in (check all that apply)*
  • Child's Date of Birth*
     - -
  • Enroll Child in (check all that apply)*
  • Child's Date of Birth*
     - -
  • Enroll Child in (check all that apply)*
  • Child's Date of Birth*
     - -
  • Enroll Child in (check all that apply)*
  • Child's Date of Birth*
     - -
  • Enroll Child in (check all that apply)*
  • Child's Date of Birth*
     - -
  • Enroll Child in (check all that apply)*
  • Child's Date of Birth*
     - -
  • Enroll Child in (check all that apply)*

  • VOLUNTARY LIFE AND AD&D INSURANCE

    You can elect coverage for yourself, your spouse, and your children
  • Dependent Voluntary Life Insurance

  • EMPLOYEE DEPENDENT & SPOUSE INFORMATION

  • Spouse's Date of Birth*
     - -
  • 1. Child's Date of Birth*
     - -
  • 2. Child's Date of Birth*
     - -
  • 3. Child's Date of Birth*
     - -
  • 4. Child's Date of Birth*
     - -
  • 5. Child's Date of Birth*
     - -
  • 6. Child's Date of Birth*
     - -

  • 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.
       
  • Date*
     - -
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