Spreadsheet: a7454036-9275-4f45-9c71-cd869c67151a
Sheet: Sheet1

WASHINGTON COLLEGE HEALTH PLAN ENROLLMENT FORM FOR ACTIVE EMPLOYEES | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10
For Medical, Dental, or Vision Coverage FY 2011 - 2012
TYPE OF ENROLLMENT |  | Check Here If New Form |  | Check Here If Change Form |  | Effective Date [MM / 1 / YYYY]
EMPLOYEE INFORMATION
Employee's Last Name |  |  |  | First Name |  | MI | Social Security Number * |  | Birth Date | Sex F/M
Mailing Address |  |  |  |  |  |  | Status FT/PT | Hours/Week | Hire Date | Visiting Y / N
City, State, Zip |  |  |  |  |  |  | College Telephone Number |  | Home/Cell Telephone Number
DEPENDENT INFORMATION
Add    ____   [NAME]   ____
 | Spouse/Partner Last Name [If Different] |  |  | First Name |  | MI | Social Security Number * |  | Birthdate | Sex F/M
Add    ____   [NAME]   ____
 | Child Last Name [If Different] |  |  | First Name |  | MI | Social Security Number * |  | Birthdate | Sex F/M
Add    ____   [NAME]   ____
 | Child Last Name [If Different] |  |  | First Name |  | MI | Social Security Number * |  | Birthdate | Sex F/M
Add    ____   [NAME]   ____
 | Child Last Name [If Different] |  |  | First Name |  | MI | Social Security Number * |  | Birthdate | Sex F/M
Add    ____   [NAME]   ____
 | Child Last Name [If Different] |  |  | First Name |  | MI | Social Security Number * |  | Birthdate | Sex F/M
Add    ____   [NAME]   ____
 | Child Last Name [If Different] |  |  | First Name |  | MI | Social Security Number * |  | Birthdate | Sex F/M
Add    ____   [NAME]   ____
 | Child Last Name [If Different] |  |  | First Name |  | MI | Social Security Number * |  | Birthdate | Sex F/M
MEDICAL INSURANCE ELECTION |  |  |  |  |  |  |  | Group Policy #716711
Check Here to [NAME] or Drop All Medical Coverage |  |  |  |  |  |  |  | 20-PAY OPTION PREMIUMS
Medical Election May be Different from Other Health Plan Options. |  |  |  |  | Choice         Choice Plus L     Choice Plus H |  |  | Choice | Choice Plus L | Choice Plus H
Employee Only |  |  |  |  | $  16.10      $  20.47        $  48.37 |  |  | 20.93 | 26.611 | 62.88099999999999
Employee + Spouse or Domestic Partner |  |  |  |  | $122.94      $202.60        $248.87 |  |  | 159.822 | 263.38 | 323.53
Employee + Children |  |  |  |  | $  81.77      $157.61        $199.34 |  |  | 106.301 | 204.893 | 259.142
Employee + Family |  |  |  |  | $237.97      $339.27        $399.33 |  |  | 309.361 | 441.051 | 519.129
Employee + Family Earning < $28,000/yr |  |  |  |  | $227.97 |  |  | 296.361
 | Check Here to Continue All Medical Coverage
DENTAL INSURANCE ELECTION |  |  |  |  |  |  |  | Group Policy #00751 / Subplan ID 0001
Check Here to [NAME] or Drop All Dental Coverage |  |  |  |  |  |  |  | 20-PAY OPTION PREMIUMS
Dental Election May be Different from Other Health Plan Options. |  |  |  |  | Biweekly Premiums |  |  |  | New | Change
Employee Only |  |  |  |  | $11.73 / Biweekly Pay Pd |  |  | 15.249
Employee + Spouse or Domestic Partner |  |  |  |  | $25.79 / Biweekly Pay Pd |  |  | 33.527
Employee + Children |  |  |  |  | $17.98 / Biweekly Pay Pd |  |  | 23.374
Employee + Family |  |  |  |  | $33.47 / Biweekly Pay Pd |  |  | 43.511
 | Check Here to Continue All Dental Coverage
VISION PLAN ELECTION |  |  |  |  |  |  |  | Group Policy #[PHONE]
Check Here to [NAME] or Drop All Vision Coverage |  |  |  |  |  |  |  | 20-PAY OPTION PREMIUMS
Vision Election May be Different from Other Health Plan Options. |  |  |  |  | Biweekly Premiums |  |  |  | New | Change
Employee Only |  |  |  |  | $2.93 / Biweekly Pay Pd |  |  | 3.809
Employee + Spouse or Domestic Partner |  |  |  |  | $5.11 / Biweekly Pay Pd |  |  | 6.643000000000001
Employee + Children |  |  |  |  | $5.41 / Biweekly Pay Pd |  |  | 7.032999999999999
Employee + Family |  |  |  |  | $7.60 / Biweekly Pay Pd |  |  | 9.879999999999999
 | Check Here to Continue All Vision Coverage
EMPLOYEE CERTIFICATION
Unless I decline coverage below, I hereby certify that I am eligible for the health coverage for which I have applied, as described in the Washington College Faculty or Staff [NAME] or in the Annual Health Plan Open Enrollment Notice for 2011 - 2012 available at http://hr.washcoll.edu/pdf/health_plan_enrollment_letter.pdf.
If I am applying for health, dental, or vision insurance for a domestic partner or the children of a domestic partner, I understand that the value of health benefits provided to a domestic partner who is not a dependent for IRS income tax purposes may constitute taxable income and that I am responsible for disclosing non-dependent status of such family members below.  I understand that Washington College defines domestic partners as two individuals of the same or opposite sex who share an exclusive mutual commitment to one another, who live together, who intend to maintain their commitment indefinitely as defined at http://hr.washcoll.edu/collegepolicies_domesticpartner.php.    I  further agree that if my marriage or domestic partnership should end at any future date, I will notify Washington College.  I acknowledge that fraudulent enrollment will result in loss of benefits and may result in disallowance of any claims filed.
I HEREBY ELECT THE  HEALTH PLAN CHOICES ABOVE AND AUTHORIZE AUTOMATIC BIWEEKLY PAYROLL DEDUCTIONS, EFFECTIVE ON THE DATE INDICATED.
CHECK HERE TO DECLINE OR DROP ALL MEDICAL, DENTAL, & VISION COVERAGE.
CHECK HERE IF DEPENDENT COVERAGE DOES NOT QUALIFY FOR IRS PRE-TAX EXEMPTION. |  |  |  |  |  |  | Employee Signature |  |  | Date
 | *  Social Security Numbers for employees and covered dependents are required by the Medicare Secondary Payer Statute effective January 1, 2009.