LaFon Wax Centers – Staff – 2024 Summary of Benefits MTBCP024 PPO Summary of Benefits View Summary Summary of Benefits MTBCP053 PPO Summary of Benefits View Summary Summary of Benefits MTBCB031 PPO Summary of Benefits View Summary Summary of Benefits MTBAB302 HMO Summary of Benefits View Summary Summary of Benefits MTBAB036 HMO Summary of Benefits View Summary Plan Information LaFon Wax Centers Plan Cost Summary Cost Summary Coverage Opt-ins Suscripciones de cobertura Desired Health Plan * Plan de salud deseado MTBCP024 blue choice ppo MTBCP053 blue choice ppo MTBCB031 blue choice ppo basic MTBAB302 blue advantage hmo MTBAB036 blue advantage hmo None Who is covered? * ¿Quién está cubierto? Employee Only Employee And Spouse Employee And Children Employee And Family Name * Nombre First Name Last Name Email * Correo Electrónico Phone * Teléfono (###) ### #### Gender * Género Male Female Social Security Number * Número de seguro social Date Of Birth Fecha de nacimiento MM DD YYYY Mailing Address (Street) * Dirección postal (calle) City * Ciudad State * Estado Zip Code * Código postal Date Employed Full Time * Fecha de empleo a tiempo completo MM DD YYYY Hours Worked Per Week * Horas trabajadas por semana Annual Income * Renta anual Job Occupation/Class * Trabajo Ocupación/Clase Location * Ubicación Do you have an eligible spouse, domestic partner, or child(ren)? * ¿Tiene un cónyuge, pareja de hecho o hijos elegibles? Yes No Pay Schedule * Calendario de pago Monthly Semi-Monthly Weekly Bi-Weekly Employer Zip * Código postal del empleador Employer County * Condado del empleador Do you have an eligible spouse, domestic partner, or child(ren)? ¿Tiene un cónyuge, pareja de hecho o hijos elegibles? Name Nombre First Name Last Name Date Of Birth Fecha de nacimiento MM DD YYYY Gender Género Male Female Social Security Number Número de seguro social Relationship Relación Spouse Domestic Partner Name Nombre First Name Last Name Date Of Birth Fecha de nacimiento MM DD YYYY Gender Género Male Female Social Security Number Número de seguro social Relationship Relación Child Foster Child* Disabled Child Name Nombre First Name Last Name Date Of Birth Fecha de nacimiento MM DD YYYY Gender Género Male Female Social Security Number Número de seguro social Relationship Relación Child Foster Child* Disabled Child Name Nombre First Name Last Name Date Of Birth Fecha de nacimiento MM DD YYYY Gender Género Male Female Social Security Number Número de seguro social Relationship Relación Child Foster Child* Disabled Child Name Nombre First Name Last Name Date of Birth Fecha de nacimiento MM DD YYYY Gender Género Male Female Social Security Number Número de seguro social Relationship Relación Child Foster Child* Disabled Child *If you checked foster child, was the child placed with you by an authorized state placement agency or by order of a court? * *Si marcó niño de crianza, ¿el niño fue colocado con usted por una agencia de colocación estatal autorizada o por orden de un tribunal? Yes No **When your child, who is developmentally or physically disabled, reaches/exceeds the maximum age, an Application to Continue Disabled Child form must be completed and reviewed to determine eligibility. Is your spouse or domestic partner employed by this company? * **Cuando su hijo, que tiene una discapacidad física o de desarrollo, alcanza o excede la edad máxima, se debe completar y revisar un formulario de Solicitud para continuar con la discapacidad para determinar la elegibilidad. ¿Su cónyuge o pareja de hecho está empleado por esta empresa? Yes No Employee Dental Coverage * Cobertura dental para empleados Elect Decline Spouse or Domestic Partner Dental Coverage * Cobertura dental para cónyuge o pareja de hecho Elect Decline Child(ren) Dental Coverage * Cobertura dental para niños Elect Decline Employee Vision Coverage * Cobertura de visión para empleados Elect Decline Spouse or Domestic Partner Vision Coverage * Cobertura de visión para cónyuge o pareja de hecho Elect Decline Child(ren) Vision Coverage * Cobertura de visión para niños Elect Decline Primary Care Physician Medica de atencion primaria If selecting an HMO plan, please list the primary care physician for every covered family member. Si selecciona un plan HMO, indique el médico de atención primaria de cada miembro de la familia cubierto. Employee Primary Care Physician: Médico de atención primaria del empleado: Spouse or Domestic Partner Primary Care Physician: Médico de atención primaria del cónyuge o pareja de hecho: Dependent Primary Care Physician: Médico de Atención Primaria Dependiente: Dependent Primary Care Physician: Médico de Atención Primaria Dependiente: Dependent Primary Care Physician: Médico de Atención Primaria Dependiente: Dependent Primary Care Physician: Médico de Atención Primaria Dependiente: Important: You must elect Employee coverage in order to elect the coverage for your dependent(s). Importante: Debe elegir la cobertura de Empleado para poder elegir la cobertura para sus dependientes. *If enrolling a Domestic Partner, please attach a separate Declaration of Domestic Partnership/Enrollment Form Addendum (GP60480). *Si inscribe a una pareja de hecho, adjunte por separado un Anexo de Declaración de pareja de hecho/formulario de inscripción (GP60480). Declining Coverage Cobertura decreciente Important: If declining any coverage for yourself or any dependent, give reason. Covered under: Importante: Si rechaza alguna cobertura para usted o algún dependiente, indique el motivo. Cubierto bajo: Spouse's or Domestic Partner's Group Insurance Individual Insurance Other Coverage Offered by My Employer Other Please state your other coverage: Por favor indique su otra cobertura: Employee Agreement (Read and sign) Acuerdo de empleado (leer y firmar) I understand and agree with the following statements: • My dependents are not eligible for coverages I don't have. My dependents, including step and foster children and any over the maximum age, are eligible based on plan provisions but those over the maximum age will be verified when a claim is filed. • If I refuse dental coverage, I and my dependents may enroll later but this will affect the level of benefits. • If I refuse coverage, I cannot enroll after retirement. • If the group policy does not require my contribution, I cannot decline coverage unless the policy indicates otherwise. • If the group policy requires my contribution, I authorize my employer to deduct from my pay. • I represent all information on this form and attachments is complete and true to the best of my knowledge. They are part of this request for coverage. I agree insurance carrier is not liable for a claim before the effective date of coverage and all policy provisions apply. I have read, or had read to me, the information and my answers on this form. During the first two years coverage is in force, fraud or intentional misrepresentations can cause changes in my coverage, including cancellation back to the effective date. • Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, may be guilty of insurance fraud. • Explanation of Benefits reflecting claims payments for myself and my dependents will be sent to my home address. I also understand collection of social security numbers for myself and/or my dependents will be used by insurance carrier only as allowed by law. • I authorize insurance carrier to release data as required by law. If signed in connection with an application, reinstatement or a change in benefits, this form will be valid two years from the date below. I may revoke authorization for information not yet obtained. I understand data obtained will be used by insurance carrier for claims administration and determining eligibility for life, disability and critical illness coverage. Information will not be used for any purposes prohibited by law. A copy of this form will be as valid as the original. I declare that the information I have completed on this enrollment form is complete and true. I understand an agent or broker cannot guarantee coverage, revise rates, benefits or provisions without written approval from insurance carrier. Digitally Sign and Agree: * Name: Nombre: * I agree I do not agree Today's Date * La fecha de hoy MM DD YYYY Thank you! Back to top
