Nolan New Hire & QLE Enrollment Form 2024

  • NOLAN PAINTING HEALTHCARE ENROLLMENT FORM 2024

    All information shared on this form is secure and private.
  • Date of Hire*
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  • Date of Qualifying Life Event*
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  • Date of Birth*
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  • Marital Status*
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  • MEDICAL INSURANCE

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  • 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

    Nolan Painting will contribute a dollar-for-dollar match up to $500 per year if you are enrolled as a single, or $1,000 per year if you are enrolled with dependents. 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 Nolan'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.

  • EMPLOYEE DEPENDENT & SPOUSE INFORMATION

    (Medical & Dental)
  • 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)*

  • AUTHORIZATION AND SIGNATURE

    Please read carefully and then sign & date
    • I understand that I cannot change any of these elections for medical, dental, and dependent coverage until the next open enrollment period, unless I have 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 Nolan Painting 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 and dental premiums, I authorize Nolan Painting and all its affiliates to reduce my taxable income by an amount equal to my medical and dental 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 Nolan Painting, including some collected using this form, must be sent to the carriers of the plans in which I have enrolled. Nolan Painting and the insurance carriers will treat this information as confidential.
    • 401(k) - I acknowledge receipt of the 401(k) Summary Plan Description provided to me by Nolan Painting Human Resources.
       
    • I understand that I cannot change any of these elections for medical, dental, and dependent coverage until the next open enrollment period, unless I have 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 Nolan Painting 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 and dental premiums, I authorize Nolan Painting and all its affiliates to reduce my taxable income by an amount equal to my medical and dental 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 Nolan Painting, including some collected using this form, must be sent to the carriers of the plans in which I have enrolled. Nolan Painting and the insurance carriers will treat this information as confidential.
       
  • Date*
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  • Should be Empty: