Alpha & Omega

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Benefit Election Form 2022 - 2023

Download Benefit Options

Step 1 of 4 - Employee Information

Note: Insurance enrollment date will be on the first day of the month following the completed application date.
Enrollment Type*
- New Hire
- Change (Must be submitted within 30 Days of Qualifying Event)
- Open Enrollment
Enrollment Date*
MM slash DD slash YYYY
Date of Hire
MM slash DD slash YYYY
Client Name*
Work Location
Classification*
Pay Frequency*
Employee Details
Employee Name*
First Last
Social Security #*
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone # Home or Cell*
Marital Status*
Do you use Tobacco*
- Yes
- No
Gender*
- Female
- Male
Review Plans
Please 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.

Tier	Employee Per Pay 9.83% up to:	Dependent Per Pay	Total Per Pay
Single	$77.67	$0.00	$77.67
Employee + Spouse	$77.67	$170.88	$248.56
Employee + Child(ren)	$77.67	$139.81	$217.49
Family	$77.67	$310.69	$388.37

Tier	Employee Per Pay 9.83% up to:	Dependent / Buy Up Per Pay	Total Per Pay
Single	$77.67	$8.89	$86.56
Employee + Spouse	$77.67	$189.55	$267.22
Employee + Child(ren)	$77.67	$156.70	$234.38
Family	$77.67	$337.36	$415.04

Tier	Employee Per Pay	Dependent Per Pay	Total Per Pay
Single	$6.90	$0.00	$6.90
Employee + Spouse	$6.90	$10.77	$17.68
Employee + Child(ren)	$6.90	$6.15	$13.05
Family	$6.90	$13.04	$19.94

Tier	Employee Per Pay	Dependent /Buy Up Per Pay	Total Per Pay
Single	$6.90	$11.44	$18.35
Employee + Spouse	$6.90	$39.71	$46.61
Employee + Child(ren)	$6.90	$28.53	$35.43
Family	$6.90	$47.11	$54.01

Tier	Employee Per Pay
Single	$6.12
EE + Spouse	$12.25
EE + Child(ren)	$15.76
Family	$23.17

Tier	Employee Per Pay
Single	$2.55
EE + Spouse	$4.46
EE + Child(ren)	$5.88
Family	$7.78

Tier	Employee Per Pay
Single	$1.48
EE + Spouse	$2.81
EE + Child(ren)	$3.30
Family	$4.64

Tier	Employee Per Pay
Single	$2.32
EE + Spouse	$3.79
EE + Child(ren)	$3.78
Family	$6.10

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*
MM slash DD slash YYYY
Employee Signature*
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Full Name	SSN #	Date of Birth	Marital Status	Do you use Tobacco?	Gender	Child or Spouse?

Alpha & Omega

Benefit Election Form 2022 - 2023

Step 1 of 4 - Employee Information

Note: Insurance enrollment date will be on the first day of the month following the completed application date.

Employee Details

Review Plans

Medical Options

Dental Options

Vision Options

Options

Family Information

Life Insurance Beneficiary

Full Name	Address	Relationship