Page 2 - QCS.19 Employee Benefits

Instructions:
Please complete this entire form. After Benefit Election
completing the form, you will receive
instruction on how to complete Form 2019
FormFire Benefit Enrollment

Part I: Information Required to Set Up FormFire Benefit Enrollment
New Hire Qualified Event – Description: _________________________________________

Name: Date of Hire:
Email: Date of Birth:
Cell Phone: Last 4 of Social Security ###-##- __ __ __ __

Part II: I wish to make the following Medical benefit elections:

I wish to enroll in Medical Coverage in the I wish to enroll in Medical Coverage in the
$2,500 / $5,000 Deductible PPO Plan $2,850/$5,700 Deductible HSA Plan

Employee $185.00 per pay Employee $145.00 per pay
Employee + Spouse $350.00 per pay Employee + Spouse $300.00 per pay
Employee + Child(ren) $355.00 per pay Employee + Child(ren) $315.00 per pay
Family $425.00 per pay Family $365.00 per pay
Waive* Waive*
Health Savings Account – monthly fee:
Copays: $30 PCP / $60 Spec
$100 Urgent Care / $300 Emergency I wish to contribute $_________per pay to
Prescription Drugs: $15/$30/$75/$250 my HSA account for 2019

PPO Summary of Benefits and Coverage HSA Summary of Benefits and Coverage

Part III: I wish to make the following Dental and Vision elections:
I wish to enroll in Dental Coverage I wish to enroll in Vision Coverage

Employee $6.72 per pay Employee $1.29 per pay
Employee + Spouse $13.43 per pay Employee + Spouse $2.25 per pay
Employee + Child(ren) $14.10 per pay Employee + Child(ren) $2.45 per pay
Family $22.15 per pay Family $3.73 per pay
Waive* Waive*

*By waiving benefits, you understand that there will not be another opportunity to enroll in coverage until the next open
enrollment period unless you have a qualified event.

Part IV: HSA Employer Contribution Part IV Signature and Date (Required)
For employees enrolled in the HSA plan, I understand and agree to the following:
Queen City Skilled Care will make the • This election form is not an enrollment
application
following per pay contribution to your Health • I am required to complete the FormFire
Savings Account in the following amount: Enrollment process
• Coverage does not begin until FormFire
Employee $69.23 Enrollment is completed and signed
Employee + Spouse $115.38 Signature: ____________________________
Employee + Child(ren) $115.38
Family $138.46 Date: ________________________________

By signing this agreement, I authorize my employer to take deductions from my paycheck in accordance with a Section 125 Premium Only

Plan. Furthermore, I understand that, outside of the annual open enrollment period, I cannot change my election(s) unless I experience a

classified qualifying event under Section 125 of the Internal Revenue Service Code.
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