By signing and submitting this form I hereby apply for the benefits for which I and/or my dependents are eligible and authorize my Employer to deduct contributions, if required. I certify that I have read, or have had read to me, the completed application and that the information provided on this application is true and correct to the best of my knowledge and belief. I understand that any false statement or misrepresentation made in this application may result in loss of coverage under the group plan.
I understand that if I am enrolling in a Preferred Provider Organization (PPO) medical plan, my benefits or my dependents' benefits will be less if services are obtained from a non-preferred provider. I understand that if do not comply with the medical plan utilization review procedures, my benefits and my dependents' benefits may be reduced.
Unless otherwise elected, premiums for medical, dental and vision coverage will be deducted on a pre-tax basis. I understand that since premiums are deducted on a pre-tax basis, I cannot make a change or terminate the coverage I have elected during the plan year unless I experience a qualifying event during the plan year and notify my employer in writing. I understand that after the Open Enrollment period, I cannot make changes to my elected coverage unless I experience a change in family status, such as:
- Loss or gain of coverage through my spouse
- Loss of eligibility of a covered dependent
- Death of my covered spouse or child
- Birth or adoption of a child
- Marriage, divorce, or legal separation
- Loss of eligibility under the plan
I understand that if I experience a qualifying event I have 30 days from the change to make changes to my current coverage election. I understand that I can change my elections each year at the beginning of the Plan Year. If I terminate employment, I understand that the Plan Document will control any continued participation under this Plan. I understand that by participating in the Plan my Social Security benefits may be affected because the above elections will be deducted before my wages are taxed.