BENEFIT ELECTION FORM

Document Sample
BENEFIT ELECTION FORM Powered By Docstoc
					                        OPEN ENROLLMENT 2007
 Due in HR by November 15, 2006 for an election of new Oxford Coverage or
                        a change in Oxford Coverage
            All other elections due in HR by November 30, 2006

                           EMPLOYEE CONTRIBUTION RATES
    Please note: Unless you are a current Oxford participant (in the case of making Oxford
elections), this form will NOT enroll you in the elected plans. A Separate enrollment, change or
 termination form must be completed for each plan selected. Complete both sides of this form.

Name _________________________________________________________________
                 Last                                 First                       Middle Initial

Social Security No. _____________________ Department: ______________________

TC Box No. _______ Extension __________

                               Effective Date of Coverage: JANUARY 1, 2007

Below you will find the 2007 medical, dental and vision contribution rates. Please indicate your election(s) by
marking (X) on the appropriate box (es) below and signing the bottom of the form. (All contribution rates shown are
monthly rates).
HEALTH INSURANCE
        Plan Option             Type of Coverage & Monthly Contribution
                                         Single      2 – Party    Family
        Oxford Freedom Access Plan          [ ] $17.87        [ ] $173.00         [ ] $259.00
        * current Oxford participants will automatically be enrolled in this plan at their current coverage selection
          (single, 2-party or Family), unless they specifically opt otherwise.

        Oxford Freedom Direct Plan          [ ] $11.61         [ ] $113.06       [ ] $168.98
         *similar to the Oxford Freedom Access Plan, but with a lower reimbursement rate
        Oxford Freedom Exclusive Plan [ ] $14.14               [ ] $137.60        [ ] $205.66
        * current Aetna HMO or HIP HMO participants will automatically be enrolled in this plan, at their current
          coverage selection (single, 2-party or Family), unless they specifically opt otherwise.

I DO NOT WISH TO PARTICIPATE IN ANY OF THE COLLEGE’S MEDICAL PLANS [ ]
(Insurance Termination Form must be attached if canceling existing coverage)

DENTAL & VISION INSURANCE
        Plan Option                Type of Coverage & Monthly Contribution Cancel Coverage**
                                   Single       2 – Party   Family
        Met-Life Dental            [ ] $1.73          [ ] $45.98         [ ] $71.96                  [ ]
        Columbia Dental
        Plan Plus                  [ ] $2.00          [ ] $43.00         [ ] $68.00                  [ ]
        EyeMed Vision              [ ] $0.00          [ ] $2.15          [ ] $3.30                   [ ]
** Insurance Termination Form must be attached when canceling existing coverage



                                           TERMS AND CONDITIONS
        I hereby apply for coverage or request a change in coverage in the health care plan indicated, under the
        Teachers College’s master group contract. The information provided by me is true and correct to the best
        of my knowledge and I understand that providing false or misleading information could result in denial of
        coverage for myself or my dependents. I understand my election will remain in force from year to year,
        unless I elect to change coverage during the open enrollment period, or due to a change in family status. I
        understand that premium payments for dependent coverage will be paid by pre-tax payroll deductions
        (pursuant to the College's IRC Section 125 Benefit plan) one month in advance. I agree to inform the
        College of any life status change/qualifying event* within 30 days from the date of change. If I am declining
        enrollment for myself or my dependents because of other health insurance coverage, I may in the future be
        able to enroll myself or my dependents in this plan, provided that I request enrollment within 30 days after
        my other coverage ends. I authorize and request my employer to deduct from my salary/wages the necessary
        premiums to obtain this coverage. I understand that any benefits under this coverage will be provided in
        accordance with those described in the master group contract, including those which provide for services by
        a participating physician or hospital, pre-authorization, and required copayments by me or my dependents
        directly to the provider of such services. A photocopy of this authorization shall be as valid as the original.
        I further understand that I must be actively at work on my benefit eligibility date to be covered.


                                     AUTHORIZATION AND AGREEMENT

                         I have read and agree to the terms and conditions outlined above.

SIGNATURE:                                                                   DATE: ______________________




*A qualifying event is one of            Loss of coverage due to
the following:                           Divorce or Legal Separation                 Employer termination of group
Change in family status                  Death of Covered Employee                   health plan
Birth of a child                         Reduction of work hours                     Employer contributions have
Adoption or placement of a child         Change in status of a dependent             decreased
                                         child                                       COBRA/state continuation is
Marriage                                 Termination of employment                   exhausted


                                                                                                    Rev. 10/2006