Open Enrollment

Memorial Health System Benefits Form

Name
Colleague Number
Type of Benefits

Required Verification of Dependent Eligibility

You will receive a request via mail from ConSova Corporation to submit information to verify dependent eligibility. Keep copies of all documents submitted when requested. Failure to provide required documents and/or respond to ConSova timely will result in termination of coverage for dependent(s).

Medical Plan

Choose plan type:

Choose coverage:



If child(ren) and/or spouse coverage selected, please list the first and last name of each dependent to be covered in box below:

Dental Plan

Choose plan type:

Choose dental coverage:



If child(ren) and/or spouse coverage selected, please list the first and last name of each dependent to be covered in box below:

Vision Plan

Choose coverage:



If child(ren) and/or spouse coverage selected, please list the first and last name of each dependent to be covered in box below:

Colleague Life Insurance (Supplemental) Maximum Coverage $300,000

Choose Coverage:



Spouse Life Insurance Maximum Coverage $50,000

Choose Coverage:


Dependent Life Insurance

Choose Coverage



Healthcare Flexible Spending Account: Enter numerical amount for each deduction. Use ‘0’ if not participating.

Per Pay Period $
Annual Election Amount $

Dependent Care Flexible Spending Account: Enter numerical amount for each deduction. Use ‘0’ if not participating.

Per Pay Period $
Annual Election Amount $

Note: Each plan year contains 26 pay periods.

Dependents - List legal dependents to be added/deleted from any coverage above.

The dependents you enroll must be your legal dependents. Falsifying dependent information is considered a fraudulent act and is subject to serious penalties, including termination of employment. Please include dependent(s): First Name, Middle Initial, Last Name, Relationship, Soc Sec No, Date of Birth.

Nicotine Acknowledgment

Nicotine products include, but are not limited to, cigarettes, cigars, pipes, snuff and/or chewing tobacco, and electronic cigarettes.Colleagues who acknowledge that they and/or their spouse/civil union partner uses nicotine products will be charged a surcharge in addition to their medical premium.

Nicotine Use Certification

As a reminder, false attestations may result in loss of benefits.

Please select one of the following that applies to the colleague:
Please select one of the following that applies to the spouse/civil union partner:

Please be aware that a nicotine cessation program is offered free of charge, to colleagues and spouses/civil union partners enrolled in either medical plan, through Asset Health. Successful completion of a minimum of four (4) coaching phone calls may allow you to avoid being charged a nicotine surcharge. Once you’ve completed the four coaching calls you will need to contact the Benefits Office at 217-788-WELL (9355).

For information on Asset Health’s nicotine cessation, visit Asset Health online or call 877-549-4584.

Wellness Acknowledgment

Healthy habits start at home. Creating a healthy environment at home with your family can influence your health and the health of those around you. You and your enrolled spouse / civil union partner (if applicable) are encouraged to participate in the Health for Life program in 2021.

I understand that if I did not complete the Health for Life activities in the 2020 program year and earn 100 points (DMH colleagues exempt) , I will pay the wellness surcharge in addition to my 2021 medical premium (this applies to all colleagues hired or newly eligible before Sept. 8, 2020).

Authorization

I understand that the elections noted above will remain in effect unless I initiate changes at an annual enrollment or as a result of a qualifying event. I hereby authorize MHS to deduct the respective premiums as well as any catch-up amounts from my paycheck in accordance with my elections. I also understand that I am required to provide proof of dependent eligibility. By my electronic signature below, I attest that all information submitted on this form is true, accurate, and complete.
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Date
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Email
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