Election Forms
Dental Insurance Plan $50 Individual / $150 Family Deductible 100% Preventive / 80% Basic / 50% Major Coinsurance In Network $1000 Annual Maximum 50% Orthodontia / $1,000 Lifetime Max Per Pay Period Costs I elect this benefit (please check)
Employee Only
$ 2.52 $ 4.80 $ 6.52 $ 9.00
Employee + Spouse Employee + Child(ren)
Family
***No Dental Coverage***
I Decline Dental Coverage
_____________
Vision Insurance Plan $10 Exam Copay $130 Materials Allowance 12 /12/ 24 Contract
I elect this benefit (please check)
Per Pay Period Costs
Employee Only
$ 1.65 $ 2.76 $ 2.52 $ 4.46
Employee + Spouse Employee + Child(ren)
Family
I Decline Vision Coverage
_____________
***No Vision Coverage***
Life Insurance
Benefit
Pricing Determination Based on Job Classification One Unit per Household
Basic Life AD&D Dependent Life Voluntary Life
Based on Increments of $10,000
Voluntary Short Term Disability Voluntary Long Term Disability
Based on Income
Based on Income ___________________________________________________________________________________________________________ PLEASE READ CAREFULLY! I would like to ADD or CHANGE the following lines of coverage for 2021/2022 (check all that apply): DO NOT CHECK UNLESS YOU ARE REQUESTING A CHANGE OR ADDITION TO YOUR CURRENT COVERAGE Life _____ Dental _____ Vol Vision _____ Vol Life _____ Dep Life _____ Vol STD _____ Vol LTD_____ *Note – Evidence of insurability and/or new application may be required
__________________________________________
____________
Printed Name
Effective / Change Date
__________________________________________
_____________________
Signature
Date
13 J&L Ventures, LLC 2022 Enrollment Guide
Made with FlippingBook flipbook maker