2015 BENEFITS ACTIVE OPEN ENROLLMENT EE ID # ________ EE Contact Number ___________ PLEASE CHECK THE BENEFITS YOU WOULD LIKE TO ELECT FOR 2015 HEALTH INSURANCE PLANS HIGH PLAN 75/25/HRA 70/30 WAIVE MED (1)_______ (EE ONLY) (2)_______(EE + SPOUSE) (3)_______(EE + CHILD) (4)_______(EE + FAMILY) DENTAL PLANS Dental HMO _______ Dental EPO _______ Dental PPO _____ (1)_______ (EE ONLY) (3)_______(EE + CHILD) (2)_______(EE + SPOUSE) (4)_______(EE + FAMILY) VISION INSURANCE PLANS _____ Standard Plan ______ Buy UP Plan (1)_______(EE ONLY) (3)_______(EE + CHILD) (2)_______(EE + SPOUSE) (4)_______(EE + FAMILY) LIFE INSURANCE PLANS (can only buy up one level during open enrollment, without proving evidence of insurability) I WANT THE SUP LIFE INSURANCE (1 X)______(2 X)______(3 X)______MY SALARY ACCIDENTAL DEATH EE ONLY or EE + FAMILY COVERAGE EE ONLY _____ EE + FAMILY ______ ($_______AMOUNT OF COVERAGE) (25 K, 50 K, 100 K, 150 K, 200 K AND 250 K) DEPENDENT LIFE INSURANCE Option (1) Spouse 15 K/Dep 5 K ______ Option (2) Spouse 25 K/Dep 10 K _______ FSA (FLEXIBLE SPENDING ACCOUNT) EMPLOYEE MEDICAL SPENDING (EMSP) OR DEPENDENT CARE (DCAP) $_____EMSP $_______DCAP PRINT NAME ________ SIGNATURE ________ DATE______ PER-FRM-227 Rev 4 09/30/2014 Page 1 of 2
2015 BENEFITS ACTIVE OPEN ENROLLMENT EE ID # ________ EE Contact Number ___________ PLEASE LIST THE NAMES OF DEPENDENTS TO BE ADDED TO 2013 BENEFITS NAME OF SPOUSE/DP SOC SEC # D. O. B. DOCS VERIFIED INITIALS NAME OF DEPENDENT SOC SEC # D. O. B. DOCS VERIFIED INITIALS INITIALS INITIALS PRINT NAME ________ SIGNATURE ________ DATE______ PER-FRM-227 Rev. 4 09/30/2014 Page 2 of 2
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