Branch Manager Life Insurance
Resume:
Fixed Indemnity Medical and Ancillary Products
Enrollment Form
Complete the Enrollment Form to Elect or Decline Coverage 1. You MUST complete the Enrollment Form as part of your New Hire Process. 2. Elect or decline all benefi ts on the Enrollment Form. 3. You MUST Sign and Date the bottom of the form, even if you decline coverage. 4. Return the Enrollment Form to your Branch Manager. 5. Keep the Benefi ts at a Glance page for your records. The Essential StaffCARE Fixed Indemnity Medical, Prescription Drug, Accidental Loss of Life, Limb & Sight, Dental and Vision Plans are underwritten by BCS Insurance Company, Oakbrook Terrace, Illinois under Policy Series Numbers 25.1204, 26.1214, 26.212, and 26.213. The Term Life and Short-Term Disability Plans are underwritten by 4 Ever Life Insurance Company, Oakbrook Terrace, Illinois under Policy Series Number 62.200. For questions or assistance, please call Essential StaffCARE Customer Service at 1-866-***-****. ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF INSURANCE FRAUD AND WILL BE PROSECUTED.
THE FIXED INDEMNITY MEDICAL PLAN IS A SUPPLEMENT TO HEALTH INSURANCE. IT IS NOT A SUBSTITUTE FOR ESSENTIAL HEALTH BENEFITS COVERAGE AS DEFINED IN FEDERAL HEALTH LAW. For Enrollees of California: In order to enroll in the Fixed Indemnity Medical Benefi t, you and any dependent must have minimum essential coverage and be enrolled in major medical coverage. ESL ESC 4S^CO P1 v24.0
ESC 4S^CO P1 v24.0
A. REQUIRED EMPLOYEE INFORMATION PRINT USING BLACK or BLUE INK (Must Be Filled Out) Name Social Security # Phone Gender
M F
Address Apt. #
City State Zip Date of Birth
/ /
B. DO YOU OR ANY OF YOUR DEPENDENTS RECEIVE MEDICARE BENEFITS? Yes No. If Yes, please continue. Medicare Health Insurance Claim Number (HICN) Medicare Effective Date Name of Covered Person (s):
1. 2. 3.
C. LIMITED BENEFITS PLAN SELECTION Payroll Deducted Weekly Rates You MUST enroll in the Fixed Indemnity Medical Insurance Plan before adding any additional benefi ts in Section C. Your coverage level for the additional benefi ts in Section C will be identical to your fi xed indemnity medical plan selection. These plans are underwritten by BCS Insurance Company and 4 Ever Life Insurance Company. FIXED INDEMNITY
MEDICAL 1 DENTAL 1 VISION 1 TERM LIFE 1 SHORT-TERM DISABILITY 1,2
Employee Only $19.98 $5.40 $2.42 $0.60 $4.20
Employee + Child(ren) $33.17 $14.58 $6.54 $0.90
Employee + Spouse $37.96 $10.80 $4.84 $0.90
Employee + Family $50.55 $20.52 $9.20 $1.80
NO to ALL Benefi ts Yes No Yes No Yes No Yes No
1 This coverage is not available to residents of NH, HI, or PR. 2 STD is not available to persons who reside in CA, HI, NH, NJ, NY, or RI. For Term Life / Accidental Loss of Life, Limb & Sight, please write in your benefi ciary information. Accidental Loss of Life, Limb & Sight is part of the Fixed Indemnity Medical Benefi t. Name Relationship
D. REQUIRED DEPENDENT INFORMATION
Name Social Security # Date of Birth
/ /
Gender
M F
Relationship
Spouse Child Domestic Partner
Name Social Security # Date of Birth
/ /
Gender
M F
Relationship
Spouse Child Domestic Partner
Name Social Security # Date of Birth
/ /
Gender
M F
Relationship
Spouse Child Domestic Partner
Name Social Security # Date of Birth
/ /
Gender
M F
Relationship
Spouse Child Domestic Partner
E. REQUIRED SIGNATURE YOU MUST SIGN AND DATE, EVEN IF YOU DECLINE COVERAGE By signing below, I confi rm I have read the Benefi ts Summary and the Limitations and Exclusions for the recommended benefi t plans. I understand that open enrollment is only available for a limited time; that making no benefi t selection is a declination of benefi t coverage and benefi t coverage is only available to employees who are over the age of 18 with a valid SSN. DATE __ __ /__ __ /__ __ __ __ SIGNATURE
ENROLLMENT FORM
VSI 281700-ESL OFFICE USE ONLY LOCATION Rehire Date __ __ /__ __ /__ __ __ __ SAMPLE
FIXED INDEMNITY MEDICAL BENEFIT
The Fixed Indemnity Medical Plan pays a flat amount for a covered event caused by an accident or illness. If the covered event costs more, you pay the difference. But if the covered event costs less, you keep the difference. Outpatient Benefi ts1 Inpatient Benefi ts
Physician Offi ce Visit
(Virtual or In-Person)
$100 per day Standard Care $300 per day
Diagnostic (Lab) $75 per day Intensive Care Unit Maximum 5 $400 per day Diagnostic (X-Ray) $200 per day Inpatient Surgery $2,000 per day Ambulance Services $300 per day Anesthesia $400 per day Physical, Speech, or Occupational Therapy $50 per day Skilled Nursing 6 $100 per day Emergency Room Benefi t—Sickness $200 per day First Hospital Admission (1 per year) $250 Emergency Room Benefi t—Accident 2 $500 per day Annual Inpatient Maximum 7 No Limit Outpatient Surgery $500 per day Accidental Loss of Life, Limb & Sight Anesthesia $200 per day Employee/Spouse $20,000
Annual Outpatient Maximum $2,000 Dependent (6 months to 26 years) $5,000 Prescription Drugs (via reimbursement) 3, 4 Dependent (15 days to 6 months) $2,500 Annual Maximum $600 Wellness Care
Generic Coinsurance / Brand Coinsurance 70% / 50% Wellness Care (one per year) $100 1 all outpatient benefi ts are subject to the outpatient maximum 2 covers treatment for off the job accidents only 3 not subject to outpatient maximum 4 To fi le a claim for reimbursement, save your receipt and remit to Planned Administrators, Inc. 5 pays in addition to standard care benefi t 6 for stays in a skilled nursing facility after a hospital stay 7 subject to internal limits of plan
TERM LIFE BENEFIT
Employee Amount $10,000 (reduces to $7,500 at 65; $5,000 at 70) Child Amount (6 mos to 26 yrs old) $5,000 Spouse Amount $5,000 (terminates at age 70) Infant Amount (15 days to 6 mos) $1,000 Policy Number
WEEKLY LIMITED BENEFITS PREMIUM Medical Dental Vision Term Life STD Employee Only $19.98 $5.40 $2.42 $0.60 $4.20
Employee + Child(ren) $33.17 $14.58 $6.54 $0.90 -
Employee + Spouse $37.96 $10.80 $4.84 $0.90 -
Employee + Family $50.55 $20.52 $9.20 $1.80 -
SHORT-TERM DISABILITY BENEFIT
Benefi t Amount 60% of base pay up to $150 per week Waiting Period/Maximum Benefi t Period 7 days for injury or sickness / up to 26 weeks DENTAL BENEFIT Waiting Period/Coinsurance Annual Maximum Benefi t $750 Deductible $50 Coverage A None / 80% Exams, Cleanings, Intraoral Films, and Bitewings Coverage B 3 Months / 60% Fillings, Oral Surgery, and Repairs for Crowns, Bridges and Dentures Coverage C 12 Months / 50% Periodontics, Crowns, Endodontics, Bridges and Dentures LIMITED BENEFITS SUMMARY
For more details, please see your Summary Plan Description. VISION BENEFIT In-Network Out-of-Network
You Pay Plan Pays You Pay3 Plan Pays
Eye Exam 1 (including dilation) $10 Copay 100% 100% $35 Standard Contact Lens Fit Exam (includes follow up) Up to $55 $0 100% $0 Premium Contact Lens Fit Exam (includes follow up) 100%, after 10% discount $0 100% $0 Frames (once every 24 months) 80%, after $110 allowance 20% plus $110 allowance 100% $55 Standard Plastic Lenses (single, bifocal, trifocal) 1, 2 $25 Copay 100% 100% $25-$55 Contact Lenses (Conventional) (materials only) 1 85%, after $110 allowance 15% plus $110 allowance 100% $88 Contact Lenses (Disposable) (materials only) 1 100%, after $110 allowance $110 allowance 100% $88 Contact Lenses (Medically Necessary) (materials only) 1 $0 Copay 100% 100% $200 1 Once every 12 months 2 $15 higher in AK, CA, HI, OR, WA 3 After plan payment 281700-ESL
LIMITED BENEFIT EXCLUSIONS AND LIMITATIONS
These are the standard limitations and exclusions. As they may vary by state, please see your summary plan description (SPD) for a more detailed listing.
FIXED INDEMNITY MEDICAL AND ACCIDENTAL LOSS OF
LIFE, LIMB OR SIGHT BENEFIT
No benefi ts will be paid for loss caused by or resulting from:
• Intentionally self-infl icted injuries, suicide or any attempt while sane or insane
• Declared or undeclared war
• Serving on full-time active duty in the armed forces
• The covered person’s commission of a felony
• Work-related injury or sickness, whether or not benefi ts are payable under workers’ compensation or similar law or
• With regard to the accidental loss of life, limb or sight benefi t
- sickness, disease, bodily or mental infi rmity or medical or surgical treatment thereof, or bacterial or viral infection regardless of how contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning. No benefi ts will be paid for:
• Eye examinations for glasses, any kind of eye glasses, or vision prescriptions
• Hearing examinations or hearing aids
• Dental care or treatment other than care of sound, natural teeth and gums required on account of injury to the covered person resulting from an accident that happens while such person is covered under the policy, and rendered within 6 months of the accident
• Services rendered in connection with cosmetic surgery, except cosmetic surgery that the covered person needs for breast reconstruction following a mastectomy or as a result of an accident that happens while such person is covered under the policy. Cosmetic surgery for an accidental injury must be performed within 90 days of the accident causing the injury and while such person’s coverage is in force
• Services provided by a member of the covered person’s immediate family.
PRESCRIPTION DRUGS
No benefi ts will be paid for over-the-counter products or medications or for drugs and medications dispensed while you are in a hospital.
DENTAL
The plan will pay only for procedures specifi ed on the Schedule of Covered Procedures in the group policy. Many procedures covered under the plan have waiting periods and limitations on how often the plan will pay for them within a certain time frame. For more detailed information on covered procedures or limitations, please see your summary plan description. TERM LIFE
No Life Insurance benefi ts will be payable under the policy for death caused by suicide or self-destruction, or any attempt at it within 24 months after the person’s coverage under the policy became effective.
VISION
No benefi ts will be paid for any materials, procedures or services provided under worker’s compensation or similar law; non-prescription lenses, frames to hold such lenses, or non- prescription contact lenses; any materials, procedures or services provided by an immediate family member or provided by you; charges for any materials, procedures, and services to the extent that benefi ts are payable under any other valid and collectible insurance policy or service contract whether or not a claim is made for such benefi ts.
The fi xed indemnity medical/Rx, accidental loss of life, limb, or sight, dental, term life, and vision plans are not available to residents of Hawaii, New Hampshire, or Puerto Rico. SHORT-TERM DISABILITY
No benefi ts are payable under this coverage in the following instances:
• Attempted suicide or intentionally self-infl icted injury
• Voluntary taking of poison; voluntary inhalation of gas; voluntary taking of a drug or chemical. This does not apply to the extent administered by a licensed physician. The physician must not be you or your spouse, you or your spouse’s child, sibling or parent, or a person who resides in your home
• Declared or undeclared war or act of war
• Your commission of or attempt to commit a felony, or any loss sustained while incarcerated for the felony
• Your participation in a riot
• If you engage in an illegal occupation
• Release of nuclear energy
• Operating, riding in, or descending from any aircraft (including a hang glider). This does not apply while you are a passenger on a licensed, commercial, nonmilitary aircraft; or
• Work-related injury or sickness.
Short-Term Disability benefi ts are not available to persons who reside in California, Hawaii, New Hampshire, New Jersey, New York, or Rhode Island.
Member Services:
For frequently asked questions and network information for the Fixed Indemnity Medical Plan, please go to https://enrollment.care/info/bcs/ind.
PLEASE NOTE: To make changes or cancel coverage by telephone call the Interactive Voice Response (IVR) line at 800-***-****. Your pin code for enrolling/making changes is + _ _ _ _ (last four digits of your SSN). Your Company has chosen to take your payroll deductions on a Post-Tax basis.
Essential StaffCARE Customer Service: 1-866-***-****
• Once enrolled, members can call this number for questions regarding plan coverage, ID card, claim status, and policy booklets and to add, change, or cancel coverage.
• Customer Service Call Center hours are M - F, 8:30 a.m. to 8 p.m. Eastern Standard Time. Bilingual representatives are available.
• Members can also visit www.paisc.com and click on “Members” and enter your group number. 400
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