Page 1 - Opening Page - City/Town selection; Employee Name; Form Action
Employee Benefits Online Form
This form is HIPAA compliant. The data you enter will be stored confidentially and securely.
{citytown} {group}
{employeeName}
Benefit Review
Please use your legal name as it appears on your ID when enrolling.
This request has already been completed and the is record is locked. If you believe it was approved or declined in error, please contact Nikki Willoughby for additional assistance.
Page 2 - not used
Page 3 - Termination
{action866} for {citytown}
{employeeretireeName3}
Do not use this option if you are terminating benefits due to retirement (even if it occurs more than 30 days from now). Your benefits administrator must complete this form by selecting the "Employment or eligibility has ended" option.
This option is not available to you because your employer provides basic life and AD&D coverage for all active employees. Use the Change Enrollment form to update your benefits.
Termination of coverage from the Plan does not apply to the participant's spouse, provided the termination is because of Medicare coverage. The spouse of a retiree is permitted to maintain coverage unless the spouse is also eligible for Medicare coverage or the spouse has or is eligible for equivalent coverage.
Page 4 - Enrollment
{wpFor}
Page 5 - Benefit Selections
Medical Plan Choices:
{formMedical}
Your medical plan is the {formMedical} plan.
*The Bozeman custom medical plan is no longer available for new employees.* Please select a medical plan from the drop-down list.
Waiver of Medical/Prescription Coverage
Page 6 - Dependents
Complete this page for any dependent you are enrolling in medical, dental, vision, and/or voluntary life coverage. If enrolling your spouse, common-law spouse, or domestic partner add them as the first dependent.
Relationship Dependent Name Date of Birth Gender SSN
Page 7 - Voluntary Life
The {citytown} offers Voluntary Term Life and AD&D coverage. The employee pays this benefit 100%. Additional details on this coverage can be found in the Voluntary Term Life and AD&D Summary.
Coverage Amount: The maximum amount an employee can apply for is 5x their salary up to the maximum of $500,000. Employees may purchase benefits increments of $5,000. Spouses may receive coverage, up to 100% of the employee amount, not to exceed $500,000.
Guaranteed Issue: Up to $350,000 for Employees; $50,000 for spouses. Amounts over the Guaranteed Issue require a completed Evidence of Insurability (EOI) form.
Monthly Premium Rates per Thousand: Rates are age-banded for voluntary life and are shown below. AD&D rates are $0.05 per thousand for all ages. Volumes can be selected separately for voluntary life and AD&D coverage.
Dependent Child Benefit: Employees can cover their child(ren) in increments of $1,000, a minimum of $2,000 up to a maximum of $10,000. The cost is the same for one child or multiple children. The rate is $0.12 per $1,000 of coverage and employee coverage is required. AD&D coverage is not available for children. Eligible children must be less than 26 years of age.
Full details available at https://mmiaeb.net/wp-content/uploads/Voluntary-ADD-.pdf
**If adding or changing this coverage you must complete the Voluntary Life Enrollment Form and provide it to your benefits administrator to be submitted to MMIA upon approval of this request.
***ERROR*** The coverage you selected is greater than the coverage allowed based on your annual salary. Please select an amount equal to or less than 5x your annual salary.
Voluntary Spouse benefits are only available if the employee elects the same coverage at an equal or greater value.
You did not list a spouse (domestic partner or a common law spouse) as a covered dependent. Please complete the information below to add the coverage.
**ERROR** You may not select a coverage amount for your spouse greater than your coverage.
Voluntary Dependent Life is available only to dependent children under 26 years old.
You are requesting Voluntary Life coverage which requires an Evidence of Insurability form to be completed and provided to your benefits administrator. Additional review by the underwriters is required before the coverage is approved. You will be contacted if the request is declined or if more information is needed.
You did not select any voluntary life benefits, and will not be enrolled in this coverage.
Page 8 - Summary of Benefit enrollment/changes
This is a summary of the benefits you have elected. If you provide an email address, you will receive a copy of these benefit selections upon approval.
You are required to provide a completed and signed beneficiary form.
Please provide the completed and signed beneficiary form to your benefits administrator. It will be submitted securely to MMIA when your enrollment request is approved.
If there are errors in summary information above, click on the "Back" button to make corrections.
Page 9 - Signature Page
Participant AuthorizationI hereby request coverage for myself and my dependent(s) listed on this enrollment application who are currently enrolled or may become eligible forcoverage under the plan agreement purchased by the Montana Municipal Interlocal Authority (MMIA). I agree that my dependents and I will comply with the following:~ That we will be bound by the terms and conditions of the Group Agreement, as it may be amended;~ That all providers that have rendered services to me and my dependents are authorized to make medical information and records regarding such services available to the Plan and their providers who, in turn, may share such records among themselves; and,~ That I shall assist the Plan in the completion and submission of consents, releases, assignments, and any other documents related to the protection of the Plan’s rights under the Group Agreement including, but not limited to, the coordination of benefits with other health benefit plans, insurance policies or Medicare.I understand that I am responsible for notifying the Plan within 31 days of any changes in my or my dependent(s)’ eligibility status, such as change of address, birth, adoption of a child, marriage, divorce, termination, or additional coverages.
Statement of HIPAA Portability Rights
By selecting "No" above your request will not be processed. Please reach out to the benefits contact for {citytown} to answer any questions or address any concerns you have.
Please click on the "Submit Request" button below.
This will complete your portion of the process.
Your request requires a basic life Beneficiary Form. Please provide the completed form to your benefits administrator.
Your request requires a Domestic Partnership Affidavit. Please provide the completed form to your benefits administrator.
Your request requires a Common Law Affidavit. Please provide the completed form to your benefits administrator.
Your request requires a Voluntary Life Form. Please provide the completed form to your benefits administrator.
Your request requires an Evidence of Insurability Form. Please provide the completed form to your benefits administrator.
Your request contains errors. Please contact your benefit administrator for additional information or instructions on how to complete your request. Clicking the button below will reset the page
Page 12 - Approval Page
All of these fields are hidden from view on the form - they are used to fill, calculate, or perform some other function "behind the scenes" of the actual form
Page 5 - Dependents
Page 6 - Benefit Selections