Documents

Argon ST Open Enrollment 2008 Form Rev. 2 (Edited by Steven Thompson on Touch Smart @ 11-30-2007 6-11-44 AM)

Description
ARGON ST OPEN ENROLLMENT FORM (2008 Plan Year) Please submit form to Cathy Rudd (San Diego), Jana King (Mountain View), or Tawanna Lockhart (all other locations). A. EMPLOYEE INFORMATION Employer or Group Name: Work Location (Select One): Doylestown, PA Fort Walton Beach, FL Iraq Lexington Park, MD Last Name THOMPSON Argon ST, Inc. Mountain View, CA Newton, PA Redlands, CA San Diego, CA First Name STEVEN Apt No. Smithfield, PA Tampa, FL Ventura, CA M.I. Social Security Number L 248-31-4323 City
Categories
Published
of 4
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Related Documents
Share
Transcript
  ARGON ST OPEN ENROLLMENT FORM (2008 Plan Year) Please submit form to Cathy Rudd (San Diego), Jana King (Mountain View), or Tawanna Lockhart (all other locations). A. EMPLOYEE INFORMATION Employer or Group Name:    Argon ST, Inc. Work Location (Select One): Doylestown, PAFort Walton Beach, FLIraqLexington Park, MDMountain View, CANewton, PARedlands, CASan Diego, CASmithfield, PATampa, FLVentura, CAWindber, PAUAEHome OfficeLast Name First Name M.I.THOMPSON STEVEN LSocial Security Number  248-31-4323 Gender M FDate of Birth 9/22/1962 Street Address Apt No. City State Zip Code48 WESTERN HILLS AVENUEBEDFORDIN47421Single MarriedHome Phone( 812 ) 278-9101Work Phone( 812 ) 553-8015Work StatusFull time Part timeFormer last name (if any)Military statusActive Retired (date_______) N/AEmailsteven.thompson@argonst.com B. MEDICAL AND DENTAL COVERAGE SELECTIONS - (check all that apply): Medical Plan (Choose One): United Healthcare CHOICE (HMO)United Healthcare PPOUnited Healthcare Passive PPO (MI/PA employees only)Kaiser (CA employees only)No Coverage Coverage Level (Choose One if Electing Coverage): Employee OnlyEmployee & SpouseEmployee & Child(ren)FamilyEmployee & Domestic Partner (“DP”)Employee & DP + DP Child(ren)Employee + Child(ren) & DP Dental Plan: Employee OnlyEmployee & SpouseEmployee & Child(ren)FamilyEmployee & Domestic Partner (“DP”)Employee & DP + Child(ren)Employee + Child(ren) & DPNo Coverage C. DEPENDENT INFORMATION (List all additional members to be covered – use additional sheets if necessary) Last name First Name M.I. Date of BirthRelationship(spouse, DP,child)If child is over age 19,please indicate status and/or schoolGender Other Insurance THOMPSON JOANN E2/5/1962 spouse DisabledStudent at ______ MFYesNoEnrollCancelDisabledStudent at ______ MFYesNoEnroll   CancelDisabledStudent at ______ MFYesNoEnroll   CancelDisabledStudent at ______ MFYesNoEnroll   Cancel $$$$$$ $$   $$ $  DisabledStudent at ______ MFYesNoEnroll   Cancel Do any of your dependents live at another address? If yes, complete the following: Name: Address: D. OTHER COVERAGE INFORMATION On the day your coverage begins, will you, your spouse, or any of your dependants be covered under any health plan or policy includingMedicare or Medicaid? Yes NoIs another person legally responsible for your children? Yes NoIf you answered yes to either of the questions above, please complete the following:Person’s Name with other Health Plan: Social Security Number:Date of birth: Gender: M FOther Company’s Name and Phone Number:Other Company’s Policy Number and Effective Date: Medicare Number: Part A Effective Date:Part B Effective Date:E. MEDICAL AND DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS Medical FSA: Argon ST will fund this plan with $2,000 for full time employees;$1,500 for PT 30 hour employees; $1,000 for PT 20 hour employees. You do not need to make contributions from your ownpre-tax dollars to receive the company’s contribution.Do you wish to contribute to the Medical FSA with your own funds?Yes No  Employee Pre-tax FSA Contributions: If you yes, how much do you want to contribute for the 2008calendar year (up to $3,000): ________ (Employee Contribution Amount) Dependant Care FSA: You are able to contribute up to $5,000 of pre-tax money for dependant care expenses. You only need to enroll if you wish tocontribute money.Do you wish to participate in the Dependent Care FSA?Yes NoIf you wish to contribute, how much money do you want to add for the 2008 calendar year (up to $5,000): ________ (Employee Contribution Amount) F. LIFE/AD&D BENEFICIARY DESIGNATIONS (Use additional sheets if necessary) Life/AD&D Beneficiary Designation:Primary: Beneficiary’s Full Name: JOANN ELIZABETH THOMPSON 100% Relationship to Employee: SPOUSEBeneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________  Secondary: Beneficiary’s Full Name JASON PALMER THOMPSON 100% Relationship to Employee: SONBeneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________ Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________    $$$$  Voluntary Life/AD&D Beneficiary Designation (complete only if purchasing Voluntary Life/AD&D coverage):Primary: Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________ Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________  Secondary: Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________ Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________ Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________  Additional enrollment form must be filled out for Voluntary Life/AD&D. G. AUTHORIZATION (ALL EMPLOYEES – This form must be signed regardless of your coverage elections.) I understand and agree that any omissions or incorrect statements made on this application may invalidate my and/or my dependents’coverage. I further understand that coverage will become effective only on the date specified by the Insurer or Plan Administrator, subjectto approval by the Insurer or Plan Administrator and payment of applicable premiums. By signing this form, I hereby certify that all theinformation provided is true and correct.For contributory plans, I understand that by signing this form that I am authorizing the necessary premium deductions from my salary or wages for the coverage(s) I have selected.Where applicable to my participation elections above, on behalf of myself and anyone enrolled on this form (“Us”), I authorize any healthcare professional or entity to give United HealthCare or Kaiser and related affiliates/designees, any and all records or informationpertaining to medical history or services rendered to Us for any administrative purpose, including evaluation of an application or a claim,and for any analytical or research purposes. I also authorize on behalf of Us the use of a Social Security Number for purpose of identification.NOTICE OF ENROLLMENT RIGHTS:I understand that if I and/or my dependents, if any, waive coverage and desire to participate in the plan at a later date, coverage may besubject to treatment as a late enrollee. I further understand that if I decline enrollment for myself or my dependents (including myspouse) because of other health coverage, I may in the future be able to enroll myself or my dependents in this plan, provided that Irequest enrollment within 30 days after such coverage ends. In addition, if a new dependent relationship forms as a result of marriage,birth, adoption or placement for adoption, I may be able to enroll myself and my dependents provided that I request enrollment within 30days after such marriage, birth, adoption, or placement for adoption.X__________________________________________________________________________ __________________________ Signature of Employee Date H. Kaiser Foundation Health Plan Arbitration Agreement (This must be signed if electing Kaiser coverage) Kaiser Foundation Health Plan Arbitration Agreement: I understand that (except for Small Claims Court cases, claims subject to aMedicare appeals procedure, and, if my Group must comply with Employee Retirement Income Security Act regarding certain benefitrelated disputes) any disputebetween myself, my heirs, or other associated parties on the one hand and Health Plan, its health care providers, or other associatedparties on the other hand, for alleged violation of any duty arising out of or related to membership in Health Plan, including any claim for medical or hospital malpractice, for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legaltheory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable lawprovides for judicial review of arbitration proceedings. I agree to give up my right to a jury trial and accept the use of binding arbitration. Iunderstand that the full Arbitration provision is contained in the Evidence of Coverage .X__________________________________________________________________________ __________________________ Signature of Employee Date  Group Life and Disability Insurance products provided by Unimerica Insurance Company.   Medical and Dental Insurance products provided by United HealthCare Insurance Company and Kaiser. Enrollment Form Instructions/ChecklistAll employees MUST complete and return an enrollment form! Use the checklist below to help you through theprocess: Completed? Item Section A:Work Location – Choose OneEmployee Information – Complete requested informationSection B:Choose desired medical coverage – make sure to choose a coverage level if you elect medicalcoverageChoose desired dental coverage (available with our without medical coverage)Section C:Enter information about your dependentsAre any of your dependents at a different address?Section D:Do you or any of your dependents have other coverage?Section E:Enter amount you would like to contribute from your own funds to the Medical FlexibleSpending Account. Note – the ArgonST portion of the account is automatic – you do not have toenroll to receive this portion. You also do not have to participate in Argon ST medical or dentalcoverage to participate in this program. Plan carefully – amounts not used by the end of theplan year are forfeited by the employee.Enter the amount you would like to contribute from your own funds to the Dependent CareFlexible Spending Account.Section F:Life and AD&D Beneficiary information – enter the names of your primary beneficiaries. Also,enter the names of secondary beneficiaries who will receive the proceeds from this program if your primary beneficiary pre-deceases you.Voluntary Life and AD&D Beneficiary information – enter only if you are purchasing additionalcoverage under Argon ST’s voluntary program.Section G:All employees must read and sign the Authorization section.Section H:Sign only if you are electing coverage under the Kaiser Permanente program.

Houe click

Aug 22, 2017
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks