HEALTHCARE ENROLLMENT FORM

New Employee*

Click here if you are filling out this form because you are a new employee

Qualifying Life Event*

Click here if you are filling out this form due to a Qualifying Life Event, such as marriage, birth, or loss of coverage

Please select the reason for your change*

Date of Qualifying Life Event*

This is the date that your event occurred

Employee Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Gender*

Marital Status*

SingleMarriedDivorcedWidow/widower

Social Security Number*

Email Address*

Primary Phone Number*

Area CodePhone Number

Date of Hire*

Date

All contribution rates are per pay period*

If you are waiving Medical Coverage, please indicate the reason. (IMPORTANT: The cancellation of Medical Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.)

Please select Healthcare FSA, Dependent Care FSA, or Both

Per Pay Healthcare FSA Contribution

(26 pays per year)

Per Pay Dependent Care FSA Contribution

(26 pays per year)

Would you like to elect in full paid Life Insurance provided by Bearing & Drive Solutions?*

YesNo

Beneficiary Name:*

First NameMiddle NameLast Name

Beneficiary Date of Birth*

Date

Beneficiary Social Security Number:*

Beneficiary Relationship:*

Beneficiary Phone Number:*

Area CodePhone Number

Beneficiary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Beneficiary Date of Birth:

Date

Beneficiary Entitlement %

Employee must provide a copy of their current medical insurance card

All contribution rates are per pay period*

If you are waiving Dental Coverage, please indicate the reason. (IMPORTANT: The cancellation of Dental Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.)

All contribution rates are per pay period*

If you are waiving Vision Coverage, please indicate the reason. (IMPORTANT: The cancellation of Vision Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.)

Spouse Information

Click here if you will be adding a spouse only to your healthcare plan.

Child/Children Information

Click here if you will be adding a child/children only to your healthcare plan.

Family Information

Click here if you will be adding your spouse and child/children to your healthcare plan.

Spouse Information*

First Name, Last Name, Middle Initial

Spouse's Gender*

Spouse's Date of Birth*

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*

Child's Social Security Number*

Enroll Child in (check one or both)*

MedicalDentalVision

Child's Information*

First Name, Last Name, Middle Initial

Child's Gender*

Child's Date of Birth*

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*

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*

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*

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*

Child's Social Security Number*

Enroll Child in (check all that apply):*

MedicalDentalVision

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 Bearing & Drive Solutions. 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 Bearing & Drive Solutions. 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 Bearing & Drive Solutions, including some collected using this form, must be sent to the carriers of the plans in which I have enrolled. Bearing & Drive Solutions and the insurance carriers will treat this information as confidential.

Employee Signature*

Date*

Date

BDS HEALTHCARE ENROLLMENT FORM

MEDICAL & PRESCRIPTION INSURANCE

Flexible Spending Account (FSA)

Fully Paid Life Insurance

OTHER INSURANCE COVERAGE

DENTAL INSURANCE

VISION INSURANCE

EMPLOYEE DEPENDENT & SPOUSE INFORMATION

AUTHORIZATION AND SIGNATURE