J E Smith Services, Inc. dba JESSINC CONSOLIDATED ENROLLMENT, TERMINATION & CHANGE FORM Effective July 1, 2023 through June 30, 2024
EMPLOYEE INFORMATION
Effective Date:
Social Security Number
Date of Birth
Date of Hire
Last Name
First Name
Middle Initial
Address
Change q
City
State
Zip
County
q M q F
Gender
Phone (home or cell)
Phone (work)
Employment Class (if applicable)
Salary or Hourly Rate
# Hours worked/week
# of Pay Periods
q Single
q Full Time q Part Time q Variable
q Class 1 q Class 2 q Other
q Divorced/Separated
Marital Status
Employment Status
Job Description:
q Married q Widowed
q Other
EMPLOYEE AND DEPENDENT INFORMATION / ELECTIONS
Medical
Dental
Vision
Last Name
First Name
MI
Gender
Date of Birth
Social Security Number
United Healthcare
Principal
VBA
Option # (CBC Only)
o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive
o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive
o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive
Please indicate action to right for employee listed above
Employee
o Female o Male
Spouse/Partner
o Female o Male
Son/Dau
o Female o Male
Son/Dau
o Female o Male
Son/Dau
WAIVER OF COVERAGE (Not Enrolling) ACKNOWLEDGEMENT I have been given the opportunity to participate in the group health and welfare benefits offered by my employer. The benefits and enrollment eligibility guidelines have been explained. I understand if I choose to waive (not enroll) for myself and eligible dependents, the next opportunity to enroll would be at annual open enrollment or if I experience a qualifying life status event.
q Other Coverage (please circle applicable type and provide copy of ID card)
q Other (please describe below)
Reason for waiving:
spouse, parent, Medicare, Medicaid
(Bi-Weekly Employee Contributions)
Coverage Tier
Vision
Medical
Dental
Employee
$20.91 $276.34 $256.53 $506.02
$23.09 $26.91 $40.58 $11.29
$4.02 $8.03 $8.03 $8.03
Employee/spouse Employee/child(ren)
Employee/family
EMPLOYEE SIGNATURE By signing here, I authorize the above action as indicated and the pre-tax salary reductions from my wages for the coverage(s) elected above. The benefits and enrollment eligibility guidelines have been explained. I understand if I choose to not enroll (opt out or waive coverage) for myself and/or eligible dependents, the next opportunity to enroll will be at the next open enrollment. Exceptions include qualified life status events. I understand by checking "waiving coverage" above, I do not wish to enroll in those products at this time.
Employee name (print)
Signature
Date
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