2018 Benefit Enrollment Form

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Employee First Name(*)
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M.I.(*)
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Gender(*)
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Home Address(*)
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City(*)
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Employer Portion - Village Ford to Complete
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Occupation:
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Salary $
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Employee Bi-Weekly Cost (26 paycheck)
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MEDICAL: Health / Plan Options
Blue Cross PPO Simply Blue $1,000
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Blue Care Network HMO 20% PCP Focus
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Blue Care Network HMO $1,000 PCP Focus
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Blue Care Network HMO HSA $3,000
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DENTAL PLAN: MetLife
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VOLUNTARY VISION PLAN: EyeMed
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LIST ALL DEPENDENTS COVERED ON MEDICAL, DENTAL, AND VISION PLANS
SPOUSE
First Name
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Date of Birth
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Gender
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Relationship
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CHILD 1
First Name
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Date of Birth
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CHILD 2
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Last Name
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Date of Birth
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CHILD 3
First Name
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ACKNOWLEDGEMENT OF COVERAGE
I authorize Village Ford to make medical, dental and vision payroll deductions based on the coverage election(s) indicated above. I understand that all of the foregoing medical, dental and vision elections will be made pre-tax in accordance with my plan elections for the 2018 plan year. I further understand that if the required contributions for the elected benefit(s) change while this agreement is in effect, my payroll deductions may be automatically adjusted to reflect the change. I will receive notice of such a change.

I understand that the above election(s) are irrevocable until the next open enrollment period, unless I have a change in family status. A change in family status will include the following: a) marriage or legal separation/divorce/death, b) spouse terminating or obtaining employment, c) transfer to a different employment status (full-time to part-time or vice versa), d) significant change in spouse’s health coverage, and e) loss of dependent status or birth or adoption of a child.

Only benefit changes consistent with the above will be permitted and must be made within 30 days of the change in family status. I understand that I am responsible for notifying Village Ford of any change in family status and for completing the necessary forms within those 30 days.
Employee Name:(*)
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Date:(*)
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Employee Signature:(*)
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