Slappey and 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

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