Alpha & Omega APPLY NOW Benefit Election Form 2019 – 2020 Download Benefit Options Step 1 of 4 - Employee Information 0% Note: Insurance enrollment date will be on the first day of the month following the completed application date.Enrollment Type*New HireChange (Must be submitted within 30 Days of Qualifying Event)Open EnrollmentEnrollment Date* Date Format: MM slash DD slash YYYY Date of Hire Date Format: MM slash DD slash YYYY Client Name*Work LocationClassification*Pay Frequency*Employee DetailsEmployee Name* First Last Social Security #*Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone # Home or Cell*Marital Status*SingleMarriedDivorcedSeparatedWidowedDo you use Tobacco*YesNoGender*FemaleMaleReview PlansPlease review plans in Option 1 and Option 2. Please mark the plan you would like (and the number of people you would like to have covered by the plan) and follow the instructions under each plan. If you do not want coverage under the plan, please mark waive and follow the instructions below each section. Please choose plans in only one of the options then sign and date the submission form. *** Plans in separate options cannot be mixed. PLEASE READ CAREFULLY. Click above to download the various details on each insurance option plan's options for coverage. Note: You may only choose insurance options for plan 1 or 2, you cannot choose items of each (ie. do not choose 2A medical and 1C Dental). If you do not want to be covered under the various insurance plans, please select waive all.Medical Options Medical 1A Tier Employee Per Pay9.69% up to: Dependent Per Pay Total Per Pay Single $58.92 $0.00 $58.92 Employee + Spouse $58.92 $129.63 $188.55 Employee + Child(ren) $58.92 $106.06 $164.98 Family $58.92 $235.68 $294.61 Medical 1B Tier Employee Per Pay9.69% up to: Dependent Per Pay Total Per Pay Single $58.92 $19.59 $78.51 Employee + Spouse $58.92 $170.76 $229.68 Employee + Child(ren) $58.92 $143.28 $202.20 Family $58.92 $294.45 $353.37 Medical 2A Tier Employee Per Pay9.69% up to: Dependent Per Pay Total Per Pay Single $7.52 $0.00 $7.52 Employee + Spouse $7.52 $13.53 $21.06 Employee + Child(ren) $7.52 $8.42 $15.94 Family $7.52 $20.53 $28.05 Medical 2B Tier Employee Per Pay9.69% up to: Dependent Per Pay Total Per Pay Single $7.52 $11.26 $18.79 Employee + Spouse $7.52 $39.01 $46.53 Employee + Child(ren) $7.52 $28.60 $36.12 Family $7.52 $55.20 $62.73 Dental Options Dental 1C Tier Employee Per Pay9.69% up to: Single $4.57 EE + 1 $8.70 Family $16.60 Dental 2C Tier Employee Per Pay9.69% up to: Single $2.55 EE + Spouse $4.46 EE + Child(ren) $5.88 Family $7.78 Vision Options Vision 1D Tier Employee Per Pay9.69% up to: Single $1.61 2 Person $3.06 Family $4.50 Vision 2D Tier Employee Per Pay9.69% up to: Single $2.32 EE + Spouse $3.79 EE + Child(ren) $3.78 Family $6.10 OptionsWhich insurance options would you like?*Option 1Option 2Waive all CoverageOption 1 Medical Options*1A1BI waive medical coverageOption 2 Medical Options*2A2BI waive medical coverageOption 1 Dental Options*1CI waive dental coverageOption 2 Dental Options*2CI waive dental coverageOption 1 Vision Options*1DI waive vision coverageOption 2 Vision Options*2DI waive vision coverage1A Medical Coverage*SingleEmployee + SpouseEmployee + Child(ren)Family1B Medical Coverage*SingleEmployee + SpouseEmployee + Child(ren)FamilyNumber of Children2A Medical Coverage*SingleEmployee + SpouseEmployee + Child(ren)Family2B Medical Coverage*SingleEmployee + SpouseEmployee + Child(ren)FamilyNumber of Children1C Dental Coverage*SingleEE + 1FamilyNumber of Children2C Dental Coverage*SingleEE + SpouseEE + Child(ren)FamilyNumber of Children1D Vision Coverage*SingleEE + 1FamilyNumber of Children2D Vision Coverage*SingleEE + SpouseEE + Child(ren)FamilyNumber of Children Family InformationFill in Family Information if you want Dependents Coverage (THIS WILL BE AT 100% YOUR COST).DependentsFull NameSSN #Date of BirthMarital StatusDo you use Tobacco?GenderChild or Spouse? Life Insurance BeneficiaryLIFE INSURANCE ONLY IF TAKING MEDICAL COVERAGEBeneficiariesOnly primary and secondary beneficiaries can be listed.Full NameAddressRelationship I understand that my portion of the monthly premium elected will be deducted from my paycheck on scheduled paydays. I understand that my deductions will begin on the first check of the month in which I am eligible. Should I have a pay period without earnings or deductions, I understand that make-up deductions will be taken. If I leave employment prior to the end of the benefit month, the balance of my portion will be deducted from my final paycheck. I further understand that my benefit coverage will end according to the plan design. I understand this will be my only notice of eligibility and election, as it is my responsibility to be aware of eligibility dates/elections, and to notify EMS within 30 days of eligibility regarding any inconsistencies that appear after review of my deductions on the first check after deductions start/change. Retro changes, refunds, etc. will not be considered beyond this time.By checking the Pre-Tax boxes, I request that my benefit premiums will be deducted from my earnings before Federal taxes are withheld. In addition, I understand by checking Pre-Tax boxes, I will not be able to cancel the particular benefit(s) until "open enrollment" or if I have a "qualifying event" (i.e. birth of a child, marriage, divorce, etc.) Supporting documentation is required within 30 days of a qualifying event. By checking the Waive boxes, I do not wish to participate in the plan(s) at this time. I understand that I will not be eligible to enroll in the plan(s) until the next open enrollment period, unless I have a "qualifying event" (i.e. birth of child, marriage, divorce, etc.). Supporting documentation is required within 30 days of the qualifying event.Employee Typed Name*Date* Date Format: MM slash DD slash YYYY Employee Signature*CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.