Tierney 2025-26 Enrollment Form

Name*

First NameLast NameSuffix

I currently have the following plans- Identify the plans you participate in now*

Do you wish to make any changes for the 2025-26 Plan Year? (effective 6/1/2025)*

Changes include switching from one medical plan to another or adding or removing coverage for yourself or any dependents. If you are making no changes your payroll deductions will be updated to the new 2025-26 rates.

Date Of Birth*

Date

Phone Number

Please enter a valid phone number. On rare occasions you may receive plan information via text.

Email

example@example.com

Social Security Number

Example:123456789 (only needed if adding coverage for the first time)

Hire Date*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical Plan Choice*

Copay PlanHSA PlanNo Medical Coverage (Decline Coverage)

Dental Plan Choice*

EnrollNo Dental Coverage (Decline Coverage)

Vision Plan Choice*

EnrollNo Vision Coverage (Decline Coverage)

Spouse (only enter your Spouse's name if they are enrolling in a plan)*

Children (only enter your Children if they are enrolling in a plan)*

Click here to view the 2025 Tierney Benefits Guide

By signing this document, I recognize that I have received the Tierney Prosthetics and Orthotics Insurance Benefits and Compliance Notification Information which includes the Health Plan Compliance Notices with Summary of Benefits and Coverage (SBC) for each of the offered medical plans for the time period listed below. Additionally, I can request a copy of the SBC as indicated below. These documents are available in both electronic and paper form. Furthermore, I am aware that information concerning enrollment outside of the open enrollment period is explained below.

Plan Year: 6/1/2025 to /31/2026

It is recommended that you keep a copy of this form for you records. A copy of this form will also be kept in your employee file for future reference.

I acknowledge that I may receive additional copies of the SBC during normal business hours from:

• Chris Burnett, Office Manager

• Our Benefits Administrator:

Salem Benefits Group

(336) 723-6600 monica@salembenefits.com

Additionally, I acknowledge that I have been informed of the following information about Special Enrollment opportunities.

Important Notice of Special Enrollment:

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance (including Medicaid or Children’s Health Insurance Program (CHIP)) or group health plan coverage, you may be able to enroll yourself and the dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (other than Medicaid or CHIP) or if the employer stops contributing towards your or your dependents’ other coverage and within 60 days after the loss of Medicaid or CHIP eligibility.

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption or foster care, except when adding a dependent child will not change your coverage type or premiums that are owed.

I wish to enroll in the coverages indicated and am aware that I am responsible for the required per pay period cost indicated in my benefits booklet/guide.

Signature*

By signing, I acknowledge and agree to the statements above.

Date*

Date