Personal

Benefit Election Change

Request Form

 

Employee_________________________________             SS#___________________________________

 

Employer: 

Text Box: Instructions Step 1     Complete Employee Statement of Qualifying Event and attach applicable page to this request form. Step 2     Determine what changes you can make by reviewing the Change in Status Matrix. ·          Locate the qualifying change in status code “SC code” listed on the Employee Statement of Qualifying Event form ·          Locate that same status code “SC code” on the Matrix listed in the left hand column ·          Follow across to the column listing the benefit plan class you are interested in changing ·          Where the row and column meet, there you will find authorized changes you can make. Step 3     Complete this Personal Benefit Election Change Request Form Step 4     Sign in the Employee Signature box and return to your benefits counselor within 30 days of the qualifying change in status event.

 

 

 

 

 

 

 

 

Text Box: CHANGE IN BENEFIT ELECTION

 

 

 


Plan Classes:                                                                       5.l (Core Health)                                 5.5 (Long-Term Disability)                  5.11 (Group Dental)

                                5.2 (Non-Core Supplemental Health)           5.7 (Health FSA)                                                    5.12 (Group Vision)

                                5.3 (Group Term Life)                                  5.8 (Dependent Care AsShaffer Insurance Services, Inc.tance)                           5.13 (AD&D)

                                5.4 (Short-Term Disability)                          5.10 (Health Premium Reimbursement Account)

o   I WANT TO ELECT NEW BENEFIT(S)

Benefit

Option if Applicable
(Employee Only, Family, etc.)

Plan Class
(See above.)

Deduction Amount
per Pay Period

 

 

 

$

 

 

 

$

 

 

 

$

o   I WANT TO TERMINATE BENEFIT(S)

Benefit

Option if Applicable
(Employee Only, Family, etc.)

Plan Class
(See above.)

Deduction Amount
per Pay Period

 

 

 

$

 

 

 

$

 

 

 

$

o  I WANT TO REPLACE EXISTING BENEFIT WITH NEW BENEFIT

Benefit

Option if Applicable
(Employee Only, Family, etc.)

Plan Class
(See above.)

Deduction Amount
per Pay Period

Replace: 

 

 

$

With:     

 

 

$

o   I WANT TO CHANGE OPTIONS FOR ELECTED BENEFIT(S)

Benefit

Plan Class
(See above.)

Replace
Option

Deduction Amount
per Pay Period

With
Option

Deduction Amount
per Pay Period

 

 

 

$

 

$

 

 

 

$

 

$

 

 

 

$

 

$

o   I WANT TO CHANGE RATES FOR A ELECTED BENEFIT

Benefit

Plan Class
(See above.)


Option

From Deduction Amt
per Pay Period

To Deduction Amt
per Pay Period

 

 

 

$

$

                       

o   Text Box: Instructions If you selected SC 7.1.1 – Beginning FMLA Leave (#25) on the Employee Statement of Qualifying Event you now need to decide how you will pay your benefit premiums while you are on leave. ·         List each applicable Benefit, Plan Class (found above) and check one payment option per benefit.  Refer to the footnotes below for additional detail on each option

 

I WANT TO ELECT BENEFIT OPTIONS FOR QUALIFYING FMLA

 

 

 

 

 

 

 

 

 

 

 

 

Benefit

 

Plan Class

Options

 

 

Prepay1

Pay-As-You-Go

Catch Up

 

 

Drop

Coverage6

 

 

Pay Period2

 

 

COBRA3

 

Payroll Deduction4

 

 

Lump Sum5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1       Premiums may be pre-paid before going on FMLA leave (during same plan year) pursuant to your Cafeteria Plan.

2       While on leave, you may elect to pay premiums to the Employer at the same time that they would be paid  if by payroll deduction (with after-tax dollars)

3       While on leave, you may elect to pay premiums to the Employer at the same time that they would be paid  under COBRA which is typically once-a-month (with after-tax dollars)

4       Upon return from leave, you may “catch up” on your premiums through payroll deduction with pre-tax dollars (if you return during same plan year).  If you return after plan year has ended, you may “catch up” your premiums through payroll deductions with after-tax dollars.

5     You may make a lump sum payment (with after-tax dollars)

6     You may elect to drop coverage before going on leave.

 

Text Box: SIGNATURES

 

 

 

Text Box: Employee Signature Box Attached is my Employee Statement of Qualifying Event.   I hereby elect the benefit changes noted hereon and attest that these benefit change(s) is/are caused by and conShaffer Insurance Services, Inc.tent with the qualifying change in status code “SC #__________”.  I understand this request will not be processed until all paperwork is completed, accepted and approved by my employer.  I also realize that the elections I have elected cannot be retroactive unless I am adding a new dependent and HIPAA special enrollment rights apply.  I understand that the qualifying event and the resulting changes I have requested on this form must comply with my employer's plan, and the Plan Administrator has the sole discretion to make this determination.  If my requested changes are denied, I understand that I will have 60 days to appeal the decision.   Employee Signature_________________________________________                             Date____________________________ Text Box: Employer Signature Box                                                                  Acceptance of Change Request   Process changes in benefit elections on Pay Period No. ________________________ Pay Date:________________________   Authorized Signature:______________________________________________________ Date:___________________________ Text Box: PSP Change Entry Record                                           Shaffer Insurance Services, Inc. - Benefits Division   Date Request Received:_____________________________  Date Change Processed:_________________________   Processed by:_____________________________________     System Doc No.:_______________________________   Signed:__________________________________________     Date:_________________________________________