Your Company Name Here Inc.

Benefit Election and Authorization Form

Please complete all information in this section:

First Name:

Last Name:

SSN:

Gender:

Marital:

Address:

City:

County:

State:

Zip:

E-mail:

Phone:

Date of Birth:

Date Hired:

Copyright 2016-2020. All Rights Reserved.
Employee Benefit Information is Managed by Compass Benefit Group, LTD.
2658 Coolidge Hwy. Berkley, MI 48072. 248-433-0334.
This form and your information is encrypted using a 256-SHA cipher and is never disclosed or shared.

Health Insurance Election

Find a Provider.

Rates below are the employee's cost of insurance per pay.

Type of Coverage N/A Single 2-Person Family
HAP HMO $0.00 $57.10 $137.03 $171.29
HAP PPO $0.00 $91.58 $219.79 $274.74
Copyright 2016-2020. All Rights Reserved.
Employee Benefit Information is Managed by Compass Benefit Group, LTD.
2658 Coolidge Hwy. Berkley, MI 48072. 248-433-0334.
This form and your information is encrypted using a 256-SHA cipher and is never disclosed or shared.

Dependent Information

Please specify your dependent information.

Are You Married?

How Many Children Do You Have?



Copyright 2016-2020. All Rights Reserved.
Employee Benefit Information is Managed by Compass Benefit Group, LTD.
2658 Coolidge Hwy. Berkley, MI 48072. 248-433-0334.
This form and your information is encrypted using a 256-SHA cipher and is never disclosed or shared.

Dental Insurance Election

Rates below are the employee's cost of insurance per pay.

Type of Coverage N/A* Single EE/SP EE/Child Family
Value PPO I: $0.00 2.94 6.16 5.88 10.05
NAP PPO II: $0.00 5.47 11.49 10.98 18.77
Copyright 2016-2020. All Rights Reserved.
Employee Benefit Information is Managed by Compass Benefit Group, LTD.
2658 Coolidge Hwy. Berkley, MI 48072. 248-433-0334.
This form and your information is encrypted using a 256-SHA cipher and is never disclosed or shared.

Vision Insurance Election

Rates below are the employee's cost of insurance per pay.

Type of Coverage N/A* Single 2 Person Family
Vision: $0.00 0.78 1.19 2.09
Copyright 2016-2020. All Rights Reserved.
Employee Benefit Information is Managed by Compass Benefit Group, LTD.
2658 Coolidge Hwy. Berkley, MI 48072. 248-433-0334.
This form and your information is encrypted using a 256-SHA cipher and is never disclosed or shared.

Name Your Beneficiaries.

(primary beneficiary percentages must total 100%) If electing different beneficiaries that are not the same as those name for Basic Life, please name below.

Primary Beneficiaries:

Name:

Percentage:

Relationship:

Name:

Percentage:

Relationship:

Contingent Beneficiaries:

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

In the event the designated beneficiaries are deceased, the contingent beneficiary will receive the benefit. Employer maintains beneficiary information.

Copyright 2016-2020. All Rights Reserved.
Employee Benefit Information is Managed by Compass Benefit Group, LTD.
2658 Coolidge Hwy. Berkley, MI 48072. 248-433-0334.
This form and your information is encrypted using a 256-SHA cipher and is never disclosed or shared.

COVERAGE ACKNOWLEDGEMENT

I, hereby, acknowledge that I have been offered information to participate in Your Company's Name Medical, Dental or Vision Insurance program
and have either marked my elections or waived to participate in one or some of these plans. If I have opted out, I understand that I may not re-enter the plan, except at open enrollment or through loss of other current coverage

Signature (Type Name):

Date:

AUTHORIZATION

I have read and understand the explanation I have received regarding my options under the Benefit Program.

I authorize the company to redirect my pay on a pre-tax basis for all benefits indicated above.
I understand that the benefit options I have chosen will remain in force for the rest of the plan year and may only be changed at open enrollment or if I have a change in family status/life events.

Changes in Family Status/Life Events include:

• My marriage or divorce

• My dependent child marries

• Death of member, spouse or dependent

• Birth or adoption of a dependent

• Dependent child gains or loses full-time student status

• Eligible dependent child age reaches 25 years

• Loss of coverage for myself, spouse or eligible dependent child

I am required to notify Human Resources of Family Status/Life Events that may affect eligibility for Health and other related benefits for me or my dependents within 30 days of the event.
Failure to properly update my information may result in disciplinary action.

By signing below I attest that the dependents enrolled in the plan are eligible for coverage as defined by the Plan Guidelines.

Signature (Type Name):

Date:


I have reviewed this document before sending it.


Copyright 2016-2020. All Rights Reserved.
Employee Benefit Information is Managed by Compass Benefit Group, LTD.
2658 Coolidge Hwy. Berkley, MI 48072. 248-433-0334.
This form and your information is encrypted using a 256-SHA cipher and is never disclosed or shared.