Employee Election Form – Fill Out and Use This PDF

The Employee Election Form serves as a critical document for employees to make informed choices about their insurance and benefit options. This form allows individuals to select, waive, or modify coverage such as medical, dental, vision, life, and additional voluntary benefits, clearly outlining the effective date of coverage, and specifying employee and dependent information. It's essential for ensuring that employee selections align with their needs and circumstances. To seamlessly navigate through your insurance benefits and make the most appropriate selections, click the button below to fill out the form.

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Employee Election Form PDF Details

The Employee Election Form stands as a comprehensive document that streamlines the enrollment process for employer-provided benefits, catering to the varying needs of employees through a structured selection mechanism. It captures essential personal and employment information, including name, address, social security number, and employment status, along with specific details related to insurance coverage options such as medical, dental, vision, and life insurance. The form presents the choice to either enroll in or waive these coverages, supporting each decision with necessary information about existing coverages or reasons for waiver. For those navigating through changes in employment or personal circumstances, it outlines conditions for special enrollment periods. This ensures employees have the opportunity to adjust their benefits in alignment with their current needs, whether due to changes in marital status, loss of previously held coverage, or transitions involving dependents' coverage. By integrating sections for voluntary benefits and the acknowledgment of potential consequences for providing false information, the form balances employee autonomy with the need for accountability and informed decision-making. As it caters to both new and rehiring employees, including those eligible for COBRA/Continuation coverage, the Employee Election Form acts as a crucial tool in managing employer-employee interactions regarding benefit elections, maintaining compliance, and ensuring both parties are well-informed about the coverage options and the implications of their elections.

Question	Answer
Form Name	Employee Election Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	benefitmall employee election form, irs form for employees elect out of an employer 401 k plan template, benefit mall election form health insurance, benefit enrollment form template

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EMPLOYEE	BMLL Billing # ___________________
	BMLL Billing # ___________________
ELECTION FORM	Effective Date	___________________
ELECTION FORM	Team #	___________________
	Team #	___________________

THIS IS NOT AN APPLICATION FOR INSURANCE Carrier Group # (See Coverage Boxes)

New Hire Re-Hire COBRA/Continuation (Group Administered) Add Coverage Employer with 20 or more employees? Yes No

Last Name

First Name

M.I.

Employer

Street Address

Social Security Number

City

State

Zip

Gender

Date of Birth

Male

Female

Home Telephone #

Business Telephone #

Marital Status

Date of Marriage

Date Full-Time Employment

(

)

(

)

Started:

Are you actively working for the employer listed above (as defined in your insurance contract)?

Hours Worked/Week

Yes

Full-time

Part-time

Occupation

Employee Class

Annual Salary

MEDICAL PLAN (if offered) 1

DENTAL PLAN (if offered)

VISION PLAN (if offered)

LIFE AND AD&D (if offered)

Carrier _____________________

Carrier __________________

Carrier ___________________________

Waive Coverage*

Plan Type __________________

Plan Type _______________

Carrier Group # ____________________

Carrier Group # _____________

Carrier Group # ___________

Employee Only

VOL LIFE $ ______________________

Employee Only

Employee & Spouse

SPOUSE $ ______________________

Employee & Spouse

Employee / Child(ren)

DEP. CHILD $ __________________

Carrier _______________________________

Employee / Child(ren)

Family

______________________________________

Family

Waive Coverage*

Over 65

Retired

Working

Waive Coverage*

STD (if offered)

Waive Coverage*

LTD (if offered)

Waive Coverage*

Medicare or Complimentary to

Provider # _______________

VOL. STD

Waive Coverage*

Medicare (CareFirst-Individual

Name ___________________

VOL. LTD

Waive Coverage*

Family Dentist**

Plan # _______________________________

only; and benefit coverage only.

Name ___________________

Carrier _________________________

Benefit $ _________________________/ Wk.

Not eligible for HSA)

Benefit $ _______________________/Mo.

Carrier _______________________________

Waive Coverage*

Office # _________________

Life Insurance Beneficiary (if coverage offered)

Relationship

Social Security

Birth

Sex Stu-

Dis-

For HMO and POS Plans:

Existing

Last,

Full First,

M.I.

Number

Date

dent

abled

Primary Care &OBGyn Carrier

Patient

(Y/N)

Assigned Provider # and name

(Y/N)

Emp

Chd

OTHER HEALTH INSURANCE: Please note: You must complete this section if waiving or enrolling in medical coverage and your

company offers Dual Coverage OR if you are currently covered under Medicare.
Do you or your dependents have “health” coverage with another insurer? No Yes	IF YES: Effective Date: _____________________________
Other Carrier name/policy #____________________ Will this coverage be continued?	Yes	No IF NO: Term. Date: ____________________

Are you covered by Medicare? No Yes Effective Date (Part A) __/__/__ Effective Date (Part B) __/__/__ Medicare #____________________

Is your spouse or dependent(s) covered by Medicare? No Yes Effective Date (Part A) __/__/__ Effective Date (Part B) __/__/__

Name of spouse or dependent(s) covered (if applicable): ___________________________________________________ Medicare #_____________

*Waiver of Coverage: I certify that group insurance coverage has been offered to me and I choose to waive coverage due to: Spousal Coverage Individual Coverage Military Coverage COBRA Medicare as primary under TEFRA No Coverage

CERTIFICATION: I hereby certify that I am the spouse, parent or legal guardian of the dependent(s) shown above. Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

•Voluntary benefits may be subject to pre-existing condition exclusions (please refer to your policy for more information).

I authorize my employer to make any necessary payroll deductions and also declare that any disability coverage in force and applied for, with respect to myself, is less than 75% of my current monthly earnings (60% for intermediate disability income).

EMPLOYEE SIGNATURE ________________________________________________________________________DATE_________________

EMPLOYER SIGNATURE/VERIFICATION________________________________________________________ DATE _________________

1If enrolling in HMO coverage, please refer to the “Waiver of Insurance Coverage” included with this form. *By checking “Waive Coverage” you confirm that you waive coverage and have read and understand the “Waiver of Insurance Coverage” information included. **Dependent’s dentist if different than above.

If you have any questions concerning the benefits and services that are provided by or excluded under this agreement, please contact a membership services representative before signing this enrollment card.

P.O. Box 42827 Baltimore, MD 21284-2827

Fax: (410) 512-3984

Rev 10/09

CareFirst HMO

Waiver of Insurance Coverage

Medical- Notice of Special Enrollment Period

If you are declining enrollment for yourself or your dependent(s) (including your spouse) because of other health insurance coverage, you may be able to enroll yourself or your dependent(s) in this plan in the future, provided that you request enrollment within 30 days of the termination date of your prior coverage. If you decline enrollment for yourself or your dependent(s) because of other health insurance coverage, you must complete the section titled “Other Health Insurance” on the Election Form to preserve your future enrollment rights.

If you decline coverage for yourself or a dependent(s) because of other health coverage and do not complete the “Other Health Insurance” section on the Election Form (or provide written proof from the other plan), or do not request enrollment in within 30 days after your (and/or) dependents’ other coverage ends, you will not be eligible to enroll yourself or your dependent(s) during the enrollment period discussed above. You will then need to wait until the next open enrollment period (if applicable) to enroll in the plan’s health coverage.

If you are currently declining coverage for you or your dependent(s), you can enroll yourself and/or your dependent(s) at a later date in accordance with the following special enrollment provisions:

•You and/or your dependent(s) are no longer eligible under your spouse’s coverage:

O because your spouse’s employment or his/her group had been terminated; O you are divorced from your spouse; or

O due to the death of your spouse.

•You are no longer eligible under your parent’s coverage.

•You and/or your dependent(s) have coverage through another group but later become ineligible for coverage through the group (including COBRA participants).

•Your group health plan may also allow employees who are already enrolled for coverage to add dependents upon marriage, birth, adoption, and placement for adoption.

Please contact your Group Administrator for more detailed information on your group’s Special Enrollment Provisions.

Non-Medical

If you are voluntarily declining the non-medical coverage provided by your employer, you may choose to enroll at a later date depending upon the availability of coverage, which is now being waived. Please be aware that late enrollment may cause an increase in cost and require a health questionnaire which may delay the effective date of your coverage.

Rev. 2/10

How to Edit Employee Election Form Online for Free

With the online PDF editor by FormsPal, you can complete or change benefit enrollment form template here and now. In order to make our tool better and simpler to use, we consistently work on new features, with our users' suggestions in mind. Starting is simple! Everything you need to do is follow the next easy steps down below:

Step 1: Open the form inside our tool by pressing the "Get Form Button" at the top of this webpage.

Step 2: The tool offers you the opportunity to customize most PDF forms in a range of ways. Transform it by adding customized text, adjust original content, and include a signature - all at your fingertips!

It really is an easy task to complete the document using out detailed tutorial! Here is what you want to do:

1. You should complete the benefit enrollment form template properly, therefore take care while filling in the parts comprising these specific fields:

Ways to fill in employee coverage election letter step 1

2. Soon after finishing this part, go on to the next stage and complete all required details in these blanks - MEDICAL PLAN if offered Carrier, DENTAL PLAN if offered Carrier, Office, VISION PLAN if offered Carrier, cid LIFE AND ADD if offered cid, Life Insurance Beneficiary if, Last Full First MI, Social Security, Number, Birth Date, Sex, Stu dent YN, Dis abled YN, For HMO and POS Plans, and Primary Care OBGyn Carrier.

How to fill out employee coverage election letter stage 2

Concerning Stu dent YN and Primary Care OBGyn Carrier, make sure that you review things in this section. Those two are surely the most significant fields in the PDF.

3. This next part is considered pretty straightforward, OTHER HEALTH INSURANCE Please note, Voluntary benefits may be subject, I authorize my employer to make, EMPLOYEE SIGNATURE DATE, EMPLOYER SIGNATUREVERIFICATION, PO Box Baltimore MD Fax, and Rev - these empty fields will need to be filled in here.

Filling out section 3 in employee coverage election letter

Step 3: Prior to addressing the next stage, you should make sure that blank fields have been filled in properly. Once you confirm that it is correct, press “Done." Get hold of your benefit enrollment form template when you join for a 7-day free trial. Immediately gain access to the pdf file from your FormsPal account page, with any modifications and changes being all synced! We do not share any details you enter whenever completing forms at FormsPal.

Employee Election Form – Fill Out and Use This PDF

Employee Election Form PDF Details

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