CareBasic StaffingVALUE PLAN - CHANGE FORM
Fill out this form ONLY if you are making changes in your coverage or terminating coverage.
A. REASON FOR THE CHANGE
Reason for the Change
*
Address Change
Name Change
Add Dependent(s)
Coverage Change
Terminate Coverage
B. REQUIRED EMPLOYEE INFORMATION - MUST BE FILLED OUT
Name
*
First Name
Last Name
Social Security #
*
Phone
*
Format: (000) 000-0000.
Gender
*
M
F
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Hire Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Add/Change Dependent Information
Add/Change Dependent Information
Rows
Name
Social Security #
Date of Birth / /
Gender M F
Relationship
1
2
C. INDEMNITY PLAN CHANGES - Select the change you wish to make for each benefit
You
MUST
enroll in the
Fixed Indemnity Medical
Insurance Plan before adding any additional benefits in Section C.
Your coverage level for the additional benefits in Section C will be identical to your Fixed Indemnity Medical Plan selection.
Fixed Indemnity Medical Coverage Level
Employee Only ($15.98)
Employee + Child(ren) ($26.54)
Employee + Spouse ($30.36)
Employee + Family ($40.44)
Fixed Indemnity Medical Action
Terminate Plan
No Change
Dental Action
Enroll
Cancel
No Change
Vision Action
Enroll
Cancel
No Change
Term Life Action
Enroll
Cancel
No Change
Short-Term Disability Action
Enroll
Cancel
No Change
¹ This coverage is not available to residents of NH, HI, or PR. ² STD is not available to persons who reside in CA, HI, NH, NJ, NY, or RI.
Add/Change Life/Accidental Loss of Life, Limb and Sight Beneficiary
Primary Beneficiary
First Name
Last Name
Primary Beneficiary Relationship
Secondary Beneficiary
First Name
Last Name
Secondary Beneficiary Relationship
D. MEC PLAN CHANGES - Select the change you wish to make.
MEC Wellness/Preventive Action
Terminate MEC Plan
No Change
MEC Wellness/Preventive Coverage Level
$58.19 Employee Only
$65.79 Employee + Child(ren)
$71.00 Employee + Spouse
$80.87 Employee + Family
¹ This coverage is not available to residents of HI, or PR.
I understand that coverage may continue under my old elections until this form is received and processed by PAI. If electing benefits for the MEC plan, I hereby authorize my employer to send an enrollment request to PAI. I understand that a change in elections will be effective the 1st of the month following your credit card draft. If canceling, your coverage will terminate on the last day of the month for which a payment has been made.
I understand that making no selection in Section C and D for a benefit means I do not wish to make a change to that benefit.
DATE
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SIGNATURE
*
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