Memorial Health System Benefits Form
Name
Colleague Number
Type of Benefits
Required Verification of Dependent Eligibility
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
$
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 Use Certification
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:
Wellness Acknowledgment
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.
Signature
Date
Phone Number
Email