2025 BENEFITS GUIDE
WELCOME TO YOUR BENEFIT ENROLLMENT GUIDE 2025 PLAN YEAR
Please note: This benefit guide contains the basic information about your benefits program. It does not cover every detail; but it does provide a general description of each benefit plan. Every effort has been made to ensure that the information is accurate. However, this guide is not an insurance policy. If there is any question as to coverage, benefit eligibility, or interpretation, the insurance contract and the Certificate of Coverage you receive from the insurance carrier will govern the administration of your benefits. If you would like additional or specific information, please contact the Human Resources Department. This guide explains each type of coverage, and provides examples to help you determine your benefit and payroll deduction amounts. We encourage you to take the time to review the enrollment guide prior to enrollment. Keep in mind that the benefits you select during this enrollment will be effective April 1 st , 2025 and will continue through March 31 st. , 2026. Slappey & Sadd, LLC is proud to offer you a comprehensive benefits package for the upcoming plan year. This enrollment guide will assist you in determining the coverage levels that will provide you and your family with the protection that gives you peace of mind.
ADDITIONAL INFORMATION
ELIGIBILITY: As a Slappey & Sadd, LLC employee you may be eligible for enrollment in a variety of insurance products. Full-time employees may participate in the benefits package on first day of hire.
WHO IS AN ELIGIBLE DEPENDENT? You can enroll the following dependents in our group benefit plans: • Your legal spouse • Your natural, adopted, or stepchildren living with you, or any other children whom you have legal guardianship, up to age 26 • Unmarried children of any age if disabled and claimed as a dependent on your federal income taxes
WHEN YOU CAN ENROLL IN BENEFITS:
• During your initial new hire eligibility period • During the annual Open Enrollment period for a April 1 st effective date
If you fail to enroll within the time frame given for the new hire eligibility or annual enrollment window, you will not be able to elect benefits again until the next Open Enrollment period, and you will not have coverage, unless you experience a qualified life event. Please make your elections on time, or you may experience a delay in using your benefits.
QUALIFYING LIFE EVENTS are events that cause an individual to lose his or her group health coverage. The type of qualifying event determines who the qualified beneficiaries are for that event and the period of time that a plan must offer continuation of coverage. Qualifying Life events include: • Marriage, divorce, or legal separation • Death of spouse or other dependent • Birth or adoption of a child • You or your spouse experience a work event that effects your benefits • A dependent’s eligibility status changes due to age, student status, marital status, or employment • Relocation into or outside of your plan’s service area You must notify Human Resources within 30 days of the qualifying life event. Depending on the type of event, you may be asked to provide proof of the event. If you do not contact Human Resources within 30 days of the qualifying event, you will have to wait until the next annual enrollment period to make changes.
MEDICAL COVERAGE
Slappey & Sadd, LLC offers the following plans through Aetna.
Insurance Carrier:
Aetna Medical Insurance
Medical Plan:
$3,000 Copay Plan
In-Network: Primary Care Visits Specialist Care Visits
$35 Copay $75 Copay $75 Copay
Urgent Care
Emergency Room Care Preventative Visit Copay Diagnostic Testing (X-Ray / Blood Work) Advanced Imaging
Deductible; then $300 copay/visit
$0
Deductible; then 100% coinsurance
Deductible; then 100% coinsurance
Plan Coinsurance
100%
Employee Deductible Family Deductible
$3,000 $6,000
$6,500 (includes deductible) $13,000 (includes deductible)
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Deductible; then 100% coinsurance Deductible; then 100% coinsurance
Inpatient Hospital
Outpatient Hospital or Facility
Out-of-Network Plan Coinsurance Employee Deductible
50%
$6,000 $18,000 $16,000 $48,000
Family Deductible
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Prescription Drugs 30-day supply Tier 1 - Preferred Generic (Tier 1A / Tier 1)
$3 Copay / $10 Copay
Tier 2 - Preferred Brand
$45 Copay $75 Copay
Tier 3 - Non-Preferred Generic/Brand
Tier 4 - Specialty (Retail / Specialty)
20% Coinsurance up to $250 / 40% Coinsurance up to $500
Employee Deduction Employee Only Employee + Spouse
$0.00 $0.00 $0.00 $0.00
Employee + Child(ren)
Family
4 | Slappey & Sadd, LLC 2025 Benefits Guide
Aetna AFA Medical and Stop Loss Employee Enrollment/Change Form
Instructions: You must complete this enrollment form in full. If you do not, we will return it to you, and that can delay its processing. You alone are responsible for its accuracy and completeness. If
waiving coverage, please complete sections A and B.
Employer name
Effective date
Date of hire
Member ID number (if available)
New hire
Change of coverage
Employee termination
COBRA for:
Employee
Dependent
Rehire / reinstatement
Add spouse / civil union / domestic partner
Remove spouse / civil union / domestic partner
Length of continuation:
New group enrollment
Add dependent child
Remove dependent child
18
36
Other
Late enrollment
Name change
Cancel coverage
Original qualifying event date
Waiver
Other
Qualifying event
Open enrollment
Reason
Other
A. Employee information
Social Security number
Last name, first name, middle initial
Contact telephone (if we may contact
Work ZIP code
Work email address (if we may correspond
you by telephone)
with you via email)
(
)
-
Home address
Apt. Number City, state
Home ZIP code
Mailing address (if different from home address)
Apt. Number City, state
Mailing ZIP code
Number of hours worked a week
Check one:
Full time
1099
Seasonal
COBRA
Part time
Retired
Temporary
Union
Employee acknowledgement: I understand that it is fraud to file an application for coverage, an enrollment form or claim that contains materially false information knowingly and with intent to
defraud. It is illegal to conceal, for the purpose of misleading, information concerning any material fact. A person who commits fraud or intentionally misrepresents material facts is subject to
civil penalties and may be charged with a crime. If you commit fraud or intentionally misrepresent material facts, your coverage can be cancelled or your rates can be increased back to your
effective date.
I certify that all information and statements on this enrollment form are true and complete to the best of my knowledge. I have authority to make statements on behalf of any dependents listed
on this form. If I become aware of any new information after I have completed this enrollment form but before the effective date that would change any answer on this form or make me report something not
reported on this form, I agree to provide that information to Aetna as soon as possible.
Conditions of enrollment:
I understand and agree that my employer’s application will determine coverage and that there is no coverage unless and until Aetna approves both this enrollment form and the
employer application. I agree that my employer or its agent may send this enrollment form to Aetna. I authorize all my doctors, pharmacies, hospitals and other health care providers (“providers”) to give
Aetna any and all personal health information about me and others listed on this form. This authorization covers all health matters including those involving mental health, substance abuse and HIV / AIDS. I
further authorize Aetna to use such information and to disclose such information to affiliates, providers, payors, other insurers, third party administrators, vendors, consultants and governmental authorities
with jurisdiction when necessary for my care or treatment, payment for services, the operation of my health plan, or to conduct related activities. I have discussed the terms of this authorization with my
spouse and competent adult dependents and I have obtained their consent to those terms. This authorization will remain valid for the term of the coverage and so long thereafter as allowed by law. I
understand that I am entitled to receive a copy of this authorization upon request and that a photocopy is as valid as the original.
Please sign here ONLY if you are enrolling in coverage for yourself and / or dependents.
X Employee signature
Date (Month/Day/Year)
GR-69452 (3-24)
SG AFA IMQ R-POD
1
A
5 Slappey & Sadd, LLC 2025 Benefits Guide |
B. Decline / waive – To be completed if medical coverage is declined or refused by an eligible employee and / or their eligible family members.
I acknowledge I have been given the right to apply for this coverage; however, I am electing not to enroll. By declining this group coverage I acknowledge that I and / or my dependents may have to wait until
the plan’s next anniversary date to be enrolled for group coverage. I and / or my dependents have made this decision of my / their own accord with no pressure from my employer, my employer’s agent or the
insurance carrier.
Please sign here ONLY if you are declining coverage for yourself and / or dependents.
Medical coverage declined for:
Myself
Spouse / civil union / domestic partner
Children
X Employee signature
Date (Month/Day/Year)
C. Medical coverage selection
Plan Option
D. Other medical coverage – List any individuals who will have other health insurance at the same time as this coverage.
Name of individual
Carrier Name
Name of individual
Carrier Name
E. Medicare coverage – List individuals covered by Medicare.
Name of individual
Medicare Part A
Medicare Part B
Medicare Part D
Over Age 65
Disability
End-Stage Renal Disease Effective Date
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
F. Individuals enrolling – List individuals enrolling or adding, changing or removing coverage. If more space is needed check here
and use a separate sheet of paper.
Weight Tobacco or nicotine
Dependent information
Last name, first name, middle initial
Sex
Social Security
Birthdate
Height
(A) dd
use (including
(List city, state and ZIP code for any
(M/F)
number
(MM/DD/YYYY)
(C) hange
E-cigarette devices)
dependent living at another address
(R) emove
Employee
NA
Yes
No
1.
Spouse
Civil union
Domestic partner
Yes
No
2.
Child
Stepchild
Other
Yes
No
3.
Child
Stepchild
Other
Yes
No
4.
Child
Stepchild
Other
Yes
No
5.
G. Health Questionnaire – Complete for all individuals enrolling for coverage.
Have you or anyone applying for coverage consulted with or been examined, diagnosed, or treated by any health care professionals during the last five (5) years for any illness, injury or
health condition in any of the categories listed below? If “yes,” please check the box that most appropriately describes the condition(s) and explain fully below (page 4).
1. Cancer / tumor / cyst
Yes
No
Brain
Breast
Esophagus
Stomach
Colon
Leukemia
Lymphoma
Multiple myeloma
Kidney
Liver
Lung
Melanoma
Pancreas
Prostate
)
Testicular
Cervical
Ovarian
Uterine
Throat
Thyroid
Other cancer (type / location
)
Non-malignant tumor (type / location
Diagnosis date
Cancer stage (0-4)
(if known) Cancer category (In situ, localized, regional, distant)
(if known)
Treatment:
Surgery date
Chemo timeframe
Radiation timeframe
Remission
Yes
No
If yes, provide date of remission
Continued on next page
GR-69452 (3-24)
2
SG AFA IMQ
A
6 | Slappey & Sadd, LLC 2025 Benefits Guide
G. Health Questionnaire (continued)
2. Heart / vascular
Yes
No
Aneurysm (location
)
Blocked arteries (e.g., carotid, heart, abdomen, legs)
Heart attack
Heart valve disorder
Congestive heart failure
Cardiomyopathy
Irregular or abnormal heart rhythm
Stroke
Vasculitis (type
)
Bypass / angioplasty / stent (location
)
Pacemaker or cardiac defibrillator
Other (specify details below)
3. Blood / clotting disorder
Yes
No
Hemophilia (specify type below)
Anemia (specify type below; e.g., sickle cell, hemolytic, aplastic)
Blood clots
Other (specify details below)
4. Reproductive / Gynecological
Yes
No
Current pregnancy: specify if it’s a spouse, dependent child or other expectant parent even if not listed on the application (due date
, if multiples #
, any complications
)
Intending to adopt
Infertility
Other Gynecological conditions (specify details below)
5. Gastrointestinal / endocrine
Yes
No
Diabetes
Crohn’s / ulcerative colitis
Autoimmune hepatitis
Hepatitis B (specify below if acute or chronic)
Hepatitis C (if cured, when did treatment end?
)
Cirrhosis
Pancreatitis
Growth disorder
Adrenal, pituitary, thyroid gland disorder (specify type below)
Other disorders of the gallbladder, stomach, pancreas, liver, colon (specify type below)
6. Brain / neurological
Yes
No
Amyotrophic lateral sclerosis
Cerebral palsy
Neuropathy / polyneuropathy
Multiple sclerosis
Myasthenia gravis
Muscular dystrophy
Brain and / or spinal cord disorder or injury
Paralysis, quadriplegia, paraplegia
Other (specify details below)
7. Immune / dermatology
Yes
No
HIV or AIDS
Immunodeficiency disorder
Connective tissue disorder (specify type below; e.g., lupus, scleroderma)
Hereditary angioedema
Skin disorder (specify type below; e.g., psoriasis, eczema, ulcers, infections)
Other (specify details below)
8. Lung / respiratory
Yes
No
Cystic fibrosis
COPD, chronic bronchitis, emphysema
Pulmonary hypertension
Pulmonary fibrosis
Other (specify type below; e.g., asthma, sarcoidosis, etc.)
9. Urinary / kidney
Yes
No
Kidney disease / disorder (specify type below)
Kidney failure
Dialysis: date started
Dialysis possible within the next 18 months
Bladder disorder
Prostate disorder
Other (specify details below)
10. Musculoskeletal
Yes
No
Rheumatoid or psoriatic arthritis (specify type below)
Disorder of the back / neck / spine
Disorder of the joints (specify location; e.g., hips, knees, shoulders)
Chronic pain disorder
Osteomyelitis
Amputation
Other (specify details below)
11. Mental health / substance abuse
Yes
No
Alcohol and / or drug abuse (specify type below)
Eating disorder
Anxiety / depression
Bipolar disorder
Schizophrenia
Suicide attempt
Oppositional defiant / conduct disorder
Autism
ABA therapy
Other (specify details below)
12. Transplant
Yes
No
Organ or bone marrow / stem cell transplant already performed (date
)
Future transplant planned / scheduled (date
)
Transplant discussed / recommended / possible within the next 18 months
Transplant complications
Other (specify details below)
Continued on next page
GR-69452 (3-24)
3
SG AFA IMQ
A
7 Slappey & Sadd, LLC 2025 Benefits Guide |
G. Health Questionnaire (continued)
13. Birth / inherited conditions
Yes
No
Premature birth (gestational age:
# weeks)
Congenital birth defect
Genetic / metabolic disorder
Any syndrome (specify details below)
Other (specify details below)
14. Eyes / ears / nose / throat
Yes
No
Acoustic neuroma
Cataracts
Cleft lip / palate
Deviated septum
Glaucoma
Retinopathy
Chronic ear infections
Chronic sinusitis
Other (specify details below)
15. Medications
Yes
No
Current medications:
Person
# of meds
Person
# of meds
(list medication name(s) and diagnosis below)
Medications taken within the past 12 months:
Person
# of meds
Person
# of meds
(list medication name(s) and diagnosis below)
16. Incapacitated
Yes
No
Reason:
Disabled
Handicapped
Congenital disorder
Other (specify details below)
17. Other
Yes
No (specify details below)
Hospitalizations in the past 5 years
Future surgeries or hospitalizations discussed / planned / recommended / scheduled or possible within the next 18 months
Other conditions not addressed elsewhere in the application
Provide details below for all “yes” answers indicated above. If additional space is needed, attach a separate sheet. All attachments must be signed and dated by the applicant.
Ques.
Enrollee name
Conditions /
Date
Treatment
Medication names
Dates
Is treatment ongoing?
diagnosis
diagnosed
(include surgery, hospitalized,
(include those taken orally,
treated
I f yes , provide details of any
No.
durable medical equipment /
injected, infused, topically,
current OR future treatment.
supplies, etc.)
nasally, inhaled, etc.)
GR-69452 (3-24)
4
SG AFA IMQ
A
8 | Slappey & Sadd, LLC 2025 Benefits Guide
DENTAL BENEFITS
Regular dental exams can help you and your dentist detect problems in the early stages when treatment is simpler and costs are lower.
Keeping your teeth and gums clean and healthy will prevent most tooth decay and periodontal disease, and is an important part of maintaining your medical health.
Your dental plan is through Aetna and offers “in and out-of-network” benefits.
Insurance Carrier:
Aetna Dental Insurance
PPO Dental Plan You pay:
Plan Type:
Calendar Year Deductible
$50 Individual / $150 Family
Calendar Year Maximum
$1,500
Preventive Services
100%
Basic Services
80%
Major Services
50%
Orthodontia (dependent children only)
$1,000
Out-of-Network Reimbursement
90th Usual & Customary
Employee Monthly Deduction Employee Only
$48.20
Employee + Spouse
$94.00
Employee + Child(ren)
$127.50
Family
$180.20
9 Slappey & Sadd, LLC 2025 Benefits Guide |
VISION BENEFITS
You can help protect your eyesight by visiting an eye doctor regularly. Taking care of your eyes today can lead to a better quality of life later.
The vision plan covers routine eye exams and also pays for all or a portion of the cost of glasses or contact lenses if you need them.
Your vision plan is through Aetna and offers “in and out-of-network” benefits.
Insurance Carrier:
Aetna Vision Insurance
In-Network You pay:
Out-of-Network You are reimbursed:
Eye Exam every 12 months
$10 Copay
Up to $25
Lenses every 12 months • Single Vision
$25 Copay $25 Copay $25 Copay $25 Copay
Up to $10 Up to $25 Up to $55 Up to $55
• Bifocal • Trifocal • Lenticular
Frames every 24 months
$130 Allowance + 20% off balance
Up to $65
$130 Allowance Medically Necessary: $0
Up to $104 Medically Necessary: up to $200
Contacts every 12 months
Employee Monthly Deduction Employee Only
$7.36
Employee + Spouse Employee + Child(ren)
$14.00 $14.74 $21.66
Family
*Contacts benefit is in lieu of eyeglass frames and lens benefit.
10 | Slappey & Sadd, LLC 2025 Benefits Guide
Georgia Small Group Employee
Enrollment/Change Form
Aetna Life Insurance Company
Aetna Health Inc.
Group number
INSTRUCTIONS: You must complete this enrollment form in full. If you do not, we will return it to you, and
that can delay its processing. You alone are responsible for its accuracy and completeness. If you are
Aetna member ID number (if available)
declining coverage, you must complete Section B. Please use only black ink to complete this form.
Company name
Effective date
Employee termination date
Add spouse
New hire
Add domestic partner
Rehire / reinstatement
Remove spouse
Add dependent child
New group enrollment
Remove domestic partner
Change of coverage
Late enrollment
Remove dependent child
Date of hire
Waiver
Name change
Cancel coverage
Open enrollment
Other
Loss of coverage
Address change
COBRA State continuation for:
Employee Dependent
Length of continuation:
18 months 36 months Other
Qualifying event
Original qualifying event date
Loss of coverage date
A. Employee information – You must complete this section. Please print clearly.
Social Security number
Last name, first name, middle initial
Job title
Home address
Apt. number City, state
ZIP code
Work address
City, state
ZIP code
Home telephone
Work telephone
Primary language spoken
Number of dependents, including spouse or
(optional)
domestic partner, enrolling for coverage
-
-
(
)
(
)
Salary
Number of hours
Check one:
Hourly
worked a week
Full time
1099
Seasonal
COBRA
Weekly
$
Part time
Retiree
Temporary
Union
Monthly
B. Declining coverage – Check all that apply.
I understand I am eligible to apply for this coverage through my employer. However, I am declining the coverage I checked below:
Reason for declining coverage
Employee:
Dental
Parental group coverage
Indian Health Services
Vision
Spouse / domestic partner
TRICARE / Military coverage
group coverage
Individual coverage – On Exchange
Spouse / domestic
Dental
Medicare
Individual coverage – Off Exchange
partner:
Vision
Medicaid
Another group plan provided by
Retiree coverage
my employer
Children:
Dental
COBRA coverage
Do not want
Vision
Insurance through another job
Other
I certify I have been given the right to apply for this coverage. However, I am declining coverage as noted above. By declining this group coverage, I
acknowledge that I and / or my dependents may have to wait until the plan's next anniversary date to be enrolled for group coverage.
Date (Month/Day/Year)
Please sign here ONLY if you are declining coverage for yourself and / or dependents.
I am declining coverage. Employee signature: X
Please PRINT employee name:
7000-2-SG
1
SG (1-50) GA V2 R-POD B
7000-2 (6-18)
11 Slappey & Sadd, LLC 2025 Benefits Guide |
C. Coverage selection – (Top boxes for employer and Aetna use only.)
Control/Group number
Suffix
Account
Plan number
1. Dental
Yes No
To enroll, enter the plan number and name below.
Non-voluntary plans – Plan number
Plan name
®
or
PPO
If FOC, check:
DMO
Voluntary plans – Plan number
Plan name
®
If FOC, check:
DMO
or
PPO
Before today, were you covered under this employer’s dental plan? Yes
No
Creditable coverage is allowed for new members enrolling in voluntary takeover groups. New hires please see below if applicable:
New Hire selecting a Voluntary plan and your Aetna plan is a takeover group : Were you covered for 12 months under a dental plan within the
last 90 days that included both Preventive and basic coverage? Discount dental and preventive only plans do not apply.
Yes No
Employees in AZ, CA, GA, MA, MD, MO, NC, NJ and TX must either live or work within the approved DMO ®
service area to be eligible to enroll
in the DMO ® .
Aetna Health Inc. underwrites the Aetna DMO ®
dental plans. Aetna Life Insurance Company underwrites all other Aetna dental plans.
Control/Group number
Suffix
Account
Plan number
SM
Preferred
Yes No
2. Aetna Vision
Aetna Life Insurance Company underwrites Aetna vision plans. First American Administrators, Inc. provides certain claims administration services.
EyeMed Vision Care, LLC (“EyeMed”) provides certain network administration services.
D. Individuals covered – List individuals for whom you are enrolling or adding, changing or removing coverage. Add more sheets if needed.
Employee name (Last, first, middle initial)
Sex (M/F)
Add
1
Change
Remove
Birthdate (MM/DD/YYYY)
Status
Choosing coverage for:
Single
Married
Divorced
Dental
Vision
/
/
Widowed
Legally separated
Dental provider office ID number
Current patient
Yes
Sex (M/F) Social Security number
Name (Last, first, middle initial)
Add
Spouse
Domestic partner
2
Change
Remove
Birthdate (MM/DD/YYYY)
Choosing coverage for:
/
/
Dental
Vision
Dental provider office ID number
Current patient
Yes
Sex (M/F) Social Security number
Name (Last, first, middle initial)
Child
Stepchild
Add
Other
3
Change
Remove
Birthdate (MM/DD/YYYY)
Handicapped
Choosing coverage for:
Yes No
Dental
Vision
/
/
Dental provider office ID number
Current patient
Yes
Continued on next page
7000-2-SG
7000-2 (6-18)
2
SG (1-50) GA V2 B
12 | Slappey & Sadd, LLC 2025 Benefits Guide
D. Individuals covered (Continued)
Sex (M/F) Social Security number
Name (Last, first, middle initial)
Child
Stepchild
Add
Other
4
Change
Remove
Birthdate (MM/DD/YYYY)
Handicapped
Choosing coverage for:
Yes No
Dental
Vision
/
/
Dental provider office ID number
Current patient
Yes
Sex (M/F) Social Security number
Name (Last, first, middle initial)
Child
Stepchild
Add
Other
5
Change
Remove
Birthdate (MM/DD/YYYY)
Handicapped
Choosing coverage for:
Yes No
Dental
Vision
/
/
Dental provider office ID number
Current patient
Yes
Sex (M/F) Social Security number
Name (Last, first, middle initial)
Child
Stepchild
Add
Other
6
Change
Remove
Handicapped
Choosing coverage for:
Birthdate (MM/DD/YYYY)
Yes No
Dental
Vision
/
/
Dental provider office ID number
Current patient
Yes
E. Dependent information
List any dependent in Section D with a different last name or living at another address.
Name
Address
F. Coordination of benefits
Will you have other insurance at the same time as this coverage? Yes No
If yes , will the Aetna coverage you’re applying for replace the coverage you have now?
Yes No
Name of person
Carrier name
Name of person
Carrier name
Disclosure acknowledgment
I understand that I am enrolling in a health care plan issued by Aetna Health Inc. or Aetna Life Insurance Company (“Aetna”) that requires health care
services be provided by participating providers. Failure to use a participating provider will result in reduced coverage or no coverage for services that I
receive, and I will be fully responsible for any and all costs not covered by Aetna.
I received a list of participating providers. I may verify the participation status of a provider by using the provider search at Aetna’s web site,
http://www.Aetna.com . The provider search site is updated weekly and can also be used to select a provider based on name, geographic location,
group practice, medical specialty and / or hospital affiliation. I may also verify provider status by contacting Member Services at the number listed on
my member ID card. I understand that the participation status of any provider may change from time to time and that it is my responsibility to verify
participation of my health care provider with Aetna prior to receiving services.
As required by the state of Georgia regulations, the following is a summary of the financial arrangements with health care providers who are
participating in the Aetna Health Inc. network:
1. Hospital providers are paid according to a contract that includes inpatient per diems, case rates, and discounted fee for service arrangements
depending on the specific services provided.
2. Physicians are paid either a discounted fee for service in accordance with a specific fee schedule or a predetermined set amount per member per
month (capitation).
3. Laboratory services are provided through a capitation arrangement (a per member per month flat fee).
4. Other ancillary services including home health, skilled nursing, and hospice are paid on a contracted fee schedule with per diems or per visit
amounts, or through a capitated per member per month flat fee.
7000-2-SG
7000-2 (6-18)
3
SG (1-50) GA V2 B
13 Slappey & Sadd, LLC 2025 Benefits Guide |
Conditions of enrollment
I understand that the following legal entities underwrite the plans I apply for:
Aetna Health Inc. underwrites the Aetna dental DMO ®
plans.
Aetna Life Insurance Company underwrites the Aetna dental plans (except DMO ®
) and Aetna vision plans.
1. My employer’s application determines coverage. I don’t have coverage until Aetna approves my employee enrollment form and the employer
application. Even if Aetna approves the employer application, any misstatements or omissions may result in denial of future claims. Aetna may
rescind or reevaluate my coverage under the policy, as of the effective date, for eligibility and rating purposes. If Aetna voids or rescinds
coverage, I may be entitled to a refund of any paid premiums from the effective date of coverage. Aetna will give at least 30 days advance written
notice to any covered person affected by the proposed rescission. If I elect to receive electronic notifications, I will receive this notice in an
electronic (email) format.
2. To support the coverages listed on this enrollment form, Aetna may need information about medical history, services or treatment provided to
anyone listed on this form. This may include information about mental health, substance use disorder and HIV / AIDS. I authorize that the
following entities can provide this information to Aetna or its agents:
Physicians
Other healthcare professionals
Hospitals
Other healthcare organizations (“providers”), including
Pharmacies
–
Pharmacy database benefit managers
–
3. I authorize Aetna to use and disclose such information to:
Affiliates
Providers
Other insurers
Third party administration
Vendors
Consultants
Governmental authorities with jurisdiction when necessary for:
Care or treatment
–
Payment for services
–
Operation of my health plan
–
Conduct related activities
–
4. I discussed the terms of this authorization with my competent adult dependents. They agreed to these terms. This authorization is valid for 30
months from the signature date. This authorization is valid for the term of the coverage for medical information collected in connection with a
medical claim. This authorization is voluntary. But if I don’t sign this form, my ability to enroll in the plan may be affected. I have the right to
revoke this authorization in writing to Aetna at any time. I can’t revoke authorization for information already used or disclosed before I revoked my
authorization. I am entitled to receive a copy of this authorization upon request. A photocopy is as valid as the original.
The Group Agreement / Group Policy determines the rights and responsibilities of members and will govern in the event they conflict with any:
Benefits comparison
–
Summary
–
Other description of the plan
–
Participating physicians, hospitals and other health care providers are independent contractors. They are not Aetna agents or employees.
We cannot guarantee the availability of any particular provider. Any provider network is subject to change. We will provide a notice of the
change in accordance with applicable state law.
5. I understand that, with certain exceptions described in the plan documents, HMO and DMO ©
plans only provide coverage for network covered
benefits. The plan documents also describe if I need a referral for certain procedures, and who can provide care. Covered services must be
performed by:
Participating primary care physicians
Participating primary care dentists
Participating specialists
Participating hospitals
Participating pharmacies
Participating dentists
Other participating providers as authorized by a referral from a participating primary care physician
6. I authorize the substitution of generic pharmaceuticals for the brand-name products, as provided by law, for prescriptions filled under any
pharmacy benefit.
Continued on next page
7000-2-SG
7000-2 (6-18)
4
SG (1-50) GA V2 B
14 | Slappey & Sadd, LLC 2025 Benefits Guide
Conditions of enrollment (Continued)
I represent that all information supplied in this form is true and complete. I have read and agree to the conditions of enrollment and misrepresentation
on this Employee Enrollment / Change Form.
I understand that if I don’t sign this form within 31 days or Aetna does not receive the request within a reasonable time, my eligibility may be affected.
I am employed by the employer shown on page 1. I am working full time or at least 25 hours a week for this employer at the regular place of business. I
authorize deductions from my earnings for any contributions required for coverage. I agree to make any necessary payments required for coverage.
I have read and understand the information provided in the Disclosure section of this form.
To receive documents online, please visit your secure member account at Aetna.com.
Misrepresentation: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any person who knowingly and with intent
to defraud any insurance company or other person files an enrollment form for insurance or statement of claim containing any materially false
information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a
crime and subjects such person to criminal and civil penalties.
Please sign here ONLY if you are enrolling in coverage for yourself
Employee email
Date (Month/Day/Year)
and / or dependents.
Employee signature (required)
7000-2-SG
SG (1-50) GA V2 B
7000-2 (6-18)
5
15 Slappey & Sadd, LLC 2025 Benefits Guide |
BASIC LIFE AND AD&D INSURANCE COVERAGE
Slappey & Sadd, LLC provides all Full-Time employees with Basic Life and Accidental Death & Dismemberment at no cost to you.
Humana Basic Life w/AD&D Insurance
Eligibility Requirement
All Full-Time Employees
Life Insurance Benefit
$25,000
Guarantee Issue
Yes
Accidental Death & Dismemberment Benefit (AD&D)
Same as Basic Life Amount
Visit us at Humana.com
Small Group Employee Enrollment Form - 1-50 Employees
GEORGIA
The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in the Small Group Employee Enrollment Form as “Humana”. To elect primary care physician or dentist, please complete reorder GA-51340-PP. HMO and POS plans offered by Humana Employers Health Plan of Georgia, Inc., and/or insured or administered by Humana Insurance Company. PPO and Indemnity Medical plans and Life plans insured or administered by Humana Insurance Company. Dental plans insured or administered by HumanaDental Insurance Company or Humana Insurance Company. PrePaid Dental Plans offered by Humana Employers Health Plan of Georgia, Inc. Vision plans insured or administered by HumanaDental Insurance Company or Humana Insurance Company.
Please print clearly and fill in each applicable circle.
Proposed effective date: _ _ / _ _ / _ _ _ _
Employer / Group name
Employer / Group city
State
Qualifying Event Instructions m New business enrollment m New hire / Newly eligible
Date of Qualifying Event: _ _ / _ _ / _ _ _ _
m Open Enrollment event m Rehire / Reinstatement
m Dependent birth or adoption m Marital status change
m Loss of coverage
m Other___________________
Enrollment information
Social Security Number N/A (complete in Employee/ Individual Information section.)
Disabled? If yes, indicate reason below.
Relationship
Last name, First name MI
Gender Date of birth m F m M __/__/____ m F m M __/__/____ m F m M __/__/____ m F m M __/__/____ m F m M __/__/____ m F m M __/__/____
m Y m N m Y m N m Y m N m Y m N m Y m N m Y m N
Employee / Individual
Spouse / Domestic Partner
Child / Dependent Child / Dependent Child / Dependent
Other (specify):
Employee / Individual Information
Hours worked per week:
Date of full time hire: _ _ / _ _ / _ _ _ _
Social Security Number
Street address
APT / Suite / Box
City
State
ZIP code
Phone # ( )
Language: m English m Spanish m Other E-mail address Occupation Are you actively at work? m Y m N If not, reason: m Retiree m COBRA Other: _______________ Annual salary $ Prior / Existing Coverage: IMPORTANT - DO NOT cancel any existing coverage until you receive written notification from Humana of your acceptance for coverage. Medical 1. Prior medical coverage during the past 18 months (individual or other group coverage)? m N m Y Prior medical insurance carrier name Policy # Prior coverage type: m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family Effective date _ _ / _ _ / _ _ _ _ Term date _ _ / _ _ / _ _ _ _ 2. Other medical coverage in effect at the same time as this Humana coverage (individual or other group coverage)? m N m Y Other medical insurance carrier name Policy # Other coverage type: m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family Effective date _ _ / _ _ / _ _ _ _ Term date _ _ / _ _ / _ _ _ _
3. Medicare Employee / Individual coverage: m N m Y Medicare ID
Effective date _ _ / _ _ / _ _ _ _ Term date _ _ / _ _ / _ _ _ _ Effective date _ _ / _ _ / _ _ _ _ Term date _ _ / _ _ / _ _ _ _
Medicare ID
Spouse coverage: m N m Y
GA-72000 10/2015
1
Reorder# GA-52000-SB 1/2018
17 Slappey & Sadd, LLC 2025 Benefits Guide |
First name:
Last name:
Dental 1. Prior dental coverage during the past 12 months (individual or other group coverage)? m N m Y 2. Prior orthodontia coverage in the past 12 months? m N m Y Prior dental insurance carrier name Policy #
Prior coverage type: m Employee / Individual only
m Employee / Individual and spouse m Employee / Individual and child(ren) m Family
Effective date _ _ / _ _ / _ _ _ _ Term date _ _ / _ _ / _ _ _ _
Prior carrier phone # (
)
Coverage Options Medical
Group #:
Benefit #:
Class/Div:
Plan name:
Coverage type:
m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family m No Coverage (complete waiver)
Health Savings Account Class/Div: If you have medical coverage under another plan, you may not be eligible for an HSA. Please check with your tax advisor for details. Please refer to Humana’s HSA contribution worksheet to calculate your maximum allowed contribution. You can find additional information on HSAs on Humana.com. Select the Quick Link for Spending Account information on the Member page. Do you elect the Health Savings Account? m N m Y (If no, complete waiver.) Group #: Benefit #: Beneficiary for this account will be the employees / individual’s estate. You may change beneficiary information on file with the bank that administers the HSA once the account is established.
Dental
Group #:
Benefit #:
Class/Div:
Plan name:
Coverage type:
m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family m No Coverage (complete waiver)
Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly)
Basic Life /Accidental Death and Dismemberment
Group #:
Benefit #:
Class/Div:
Class (employer will provide you with this information, if needed)
Basic dependent life m N m Y (If no, complete waiver.)
Voluntary Life Accidental Death and Dismemberment
Group #:
Benefit #:
Class/Div:
Amount (min $15,000) $
Voluntary employees / individual life coverage m N m Y
Voluntary spouse life coverage? m N m Y Amount (min $5,000) $
Voluntary child(ren) life coverage? m N m Y
Vision
Group #:
Benefit #:
Class/Div:
Plan name:
Coverage type:
m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family m No Coverage (complete waiver)
Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly) Rate Amount $_______ Rate Frequency (Monthly)
Beneficiary Information for Life Primary beneficiary name (Last, First MI)
Relationship to Employee / Individual
Secondary beneficiary name (Last, First MI)
Relationship to Employee / Individual
Evidence of Health Status - Do not submit more than 90 days prior to the effective date. Complete this section if you are selecting Life over the guarantee issue amount. ALL MEDICAL QUESTIONS SHOULD BE ANSWERED IN RELATION TO TREATMENT OR DIAGNOSIS MADE BY A MEDICAL PROFESSIONAL OR PHYSICIAN AND ARE LIMITED TO THE LAST 10 YEARS UNLESS OTHERWISE INDICATED. 1. Is anyone on this application currently taking any prescribed medication for a recurrent condition?
m N m Y m N m Y
2a. In the past 12 months has any applicant used any tobacco product? If yes, applies to: m Employee m Spouse/Domestic Partner m Other m Child/Dependent
2b.
Is any applicant currently a smoker? If yes, applies to: m Employee m Spouse/Domestic Partner m Other m Child/Dependent
m N m Y
18 | Slappey & Sadd, LLC 2025 Benefits Guide GA-72000 10/2015
2
Reorder# GA-52000-SB 1/2018
First name:
Last name:
3. In the past 12 months, have you missed 5 or more consecutive days of work due to an injury or illness other than as a result of a cold, the flu, back problems, strained/sprained/fractured/broken limb or as a result of pregnancy? 4. Has anyone on this application been diagnosed or received treatment in the last 10 years for an immune system disorder (i.e. Lupus, ITP), AIDS or an AIDS-related complex? Acquired Immune Deficiency Syndrome (AIDS), or tested positive for AIDS or Human Immunodeficiency Virus (HIV)?
m N m Y
m N m Y
5. Within the past 5 years, has anyone on this application been diagnosed with diseases or disorders related to, counseled, consulted, or treated by a doctor, including surgery, for any of the following:
a. Coronary artery disease, chest pain, heart surgery, or any disease of the arteries, or blood disorders; anemia; hemophilia; phlebitis; high blood pressure (reading higher than 140/90)? b. Nervous, mental or emotional disorder; convulsions; epilepsy; unconsciousness; Multiple Sclerosis; Parkinson’s Disease; Cerebral Palsy?
i. Diabetes; liver or thyroid disease; hepatitis; cirrhosis; or enlargement of the lymph nodes?
m N m Y
m N m Y
j. Stomach, gall bladder, digestive, intestinal, or colon disorders?
m N m Y m N m Y m N m Y m N m Y m N m Y m N m Y
m N m Y m N m Y m N m Y m N m Y m N m Y m N m Y
c. Stroke; Transient Ischemic Attack (TIA)?
k. Rheumatoid arthritis; or back disorders; or joint disorders? l. Paralysis, or any other physical impairment or deformity? m. Chronic Fatigue Syndrome/Fibromyalgia? n. Diseases of the eye, ear, nose, or throat? Disease or disorder which has led or may lead to a permanent or progressive loss of vision, hearing or speech?
d. Emphysema; asthma, or other disease of lungs, or respiratory organs? e. End stage renal disease; disease of kidney?
f. Kidney stones; bladder?
g. Male or female organs; or infertility?
o. Alcoholism or drug habit?
h. Cancer, and/or cancerous tumor; including skin cancer? m N m Y 6. Has anyone on this application been advised by a member of the medical profession to have any diagnostic test, hospitalization, or surgery that has not been completed within the past 5 years? 7. Within the past 5 years, has anyone on this application seen a health care provider or specialist for a routine physical/wellness exam, or been seen for any reason not previously disclosed?
m N m Y
m N m Y
Height (ft / in)
Weight (lbs)
Relationship
Last name, First name MI
Employee
/ / / / /
Spouse / Domestic Partner
Child / Dependent Child / Dependent Child / Dependent Other (specify):
/ If you answered “yes” to any of the questions above, please provide details below and specify the question number. Attach additional signed and dated sheets (reorder GA-51340-MH), if necessary. Question # Person treated (Last name, First name) Condition Treatments received Medications prescribed Current or scheduled future treatments or medications Date diagnosed _ _ / _ _ / _ _ _ _ Date last seen by a doctor _ _ / _ _ / _ _ _ _
GA-72000 10/2015
3
Reorder# GA-52000-SB 1/2018
19 Slappey & Sadd, LLC 2025 Benefits Guide |
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