ENROLLMENT FORM

ENROLLMENT SUMMARY

For review purposes only. No additional changes can be submitted.

Thank you for completing the Staffmark Benefits portion of your hiring paperwork. Click the button below to close this window and enter the code word.

"health"

To complete the enrollment process, make sure to click the button below

You must enter this code in order to move on to the next page of your hiring paperwork so please write this code down so you have it when you close this window. You can also use the copy/paste feature to enter the code on the Staffmark Employment Center Benefits page. To do so, use your mouse to highlight the code on this screen, once it is highlighted press Ctrl and C buttons on your keyboard at the same time. Then go to the Code field on the Benefits page of the Staffmark Employment Center and click your mouse into the field and then press Ctrl and V buttons on your keyboard at the same time.

This is a summary of your benefit elections including your confirmation number. Final determination of benefits, exact terms and exclusions of coverage for each plan will be provided in your certificate of coverage. Coverage will become effective the Monday following your first payroll deduction of premiums.

The Benefit Guide provides rates and a summary of the benefit choices available to you.
It is very important that you click and view this information prior to completing the enrollment form.
VIEW BENEFIT GUIDE
THE FIXED INDEMNITY MEDICAL PLAN IS A SUPPLEMENT TO HEALTH INSURANCE. IT IS NOT A SUBSTITUTE FOR ESSENTIAL HEALTH BENEFITS OR MINIMUM ESSENTIAL COVERAGE AS DEFINED UNDER THE AFFORDABLE CARE ACT (ACA). The fixed indemnity medical, prescription drug, accidental loss of life, limb & sight, dental and vision plans are underwritten by BCS Insurance Company, Oakbrook Terrace, Illinois. The term life and short-term disability plans are underwritten by 4 Ever Life Insurance Company, Oakbrook Terrace, Illinois. Refer to the attached Benefit Guide for the accidental loss of life, limb & sight benefit information.
The MEC Plus plan is an employer-sponsored plan that has been deemed to be in compliance with ACA rules and regulations. This plan provides coverage for preventive services such as immunizations and routine health screenings., The plan also includes an outpatient and prescription drug benefit.

EMPLOYEE INFORMATION (* This denotes a required field)
TODAY'S DATE (MM/DD/YYYY)
EMPLOYEE SOCIAL SECURITY NUMBER (NO DASHES) *
EMPLOYEE FIRST NAME*			MI		EMPLOYEE LAST NAME*
ADDRESS1 *
ADDRESS2
CITY *		State: *		ZIP CODE *
GENDER *	DATE OF BIRTH (MM/DD/YYYY)* Benefit coverage is only available to employees who are over the age of 18.
TELEPHONE NUMBER (NO DASHES)
GROUP		ARE YOU COVERED BY MEDICARE?
EMPLOYEE MEDICARE HIC#: (NO DASHES)
EMAIL ADDRESS
If you enter your email address, you will receive a confirmation email that will include your name, last 4 digits of your SSN, benefits you elect or decline and the coverage level, if applicable. The confirmation email will also include a copy of the Benefit Guide and SBC, if applicable, for future reference. The confirmation email will be sent from enrollment@verisource.com email address, and you will need to log into the site to view the email content. Your employer may be copied on this notification.
LIMITED BENEFIT ENROLLMENT STATUS *					MEC PLUS ENROLLMENT STATUS *
Click here to view the MEC Summary of Benefits and Coverage (SBC); an important benefits document provided as required by the Affordable Care Act. For more information please visit www.healthcare.gov


CHOOSE FROM THE BENEFIT OPTIONS BELOW
FIXED INDEMNITY MEDICAL COVERAGE LEVEL ELECTION * Please note that your coverage level selected will apply to all limited benefits products.

OPTIONAL DENTAL ELECTION *
OPTIONAL VISION ELECTION *
OPTIONAL TERM LIFE ELECTION * Please Note: You cannot enroll for spouse coverage term life if your spouse's age is equal to or greater than the age of 70
OPTIONAL DISABILITY ELECTION *

DEPENDENT INFORMATION (SPOUSE OR CHILDREN)

DEPENDENT RELATIONSHIP	DEPENDENT FIRST NAME	DEPENDENT LAST NAME	DEPENDENT MEDICARE HIC#	DEPENDENT GENDER	DEPENDENT DOB (MM/DD/YYYY)	DEPENDENT SOCIAL SECURITY

BENEFICIARY NAME			RELATIONSHIP		BENEFICIARY SOCIAL SECURITY #

BENEFICIARY INFORMATION
For Accidental Loss of Life, Limb & Sight, Term Life or Accidental Death and Dismemberment, please enter your beneficiary information.


CONFIRM YOUR SOCIAL SECURITY NUMBER (NO DASHES)*
* I certify that I read the benefit packet and understand its limitations. I understand that open enrollment is only available for a limited time. This serves as my electronic signature for the above election.
Your confirmation number is 000000000. .
For questions or assistance, call customer service number listed in the Enrollment Guide.
To print a copy of this Enrollment Form, please click the "Print" button. To complete the enrollment process, make sure to click the button below
In order to submit your eForm, you must complete the certification statement and check off the certification box.

ENROLLMENT FORM

ENROLLMENT SUMMARY

For review purposes only. No additional changes can be submitted.

DEPENDENT RELATIONSHIP

DEPENDENT FIRST NAME

DEPENDENT LAST NAME

DEPENDENT MEDICARE HIC#

DEPENDENT GENDER

DEPENDENT DOB (MM/DD/YYYY)

DEPENDENT SOCIAL SECURITY

DEPENDENT
RELATIONSHIP

DEPENDENT
FIRST NAME

DEPENDENT
LAST NAME

DEPENDENT
MEDICARE HIC#

DEPENDENT
GENDER

DEPENDENT
DOB (MM/DD/YYYY)

DEPENDENT
SOCIAL SECURITY