BENEFIT ELECTIONS. See marketing materials for benefit options available by group size. A copy of the sold proposal for Life and Disability benefits must be signed and attached. ❑ Medical - ConnectiCare ❑ Group Basic Life ❑ Supplemental Life (2 to 9 eligible employees) ❑ Voluntary Life (10+ eligible employees) ❑ Voluntary Dependent Life (10+ eligible employees) ❑ Group Dental Prior dental coverage? ❑ Yes ❑ No ❑ 10+ eligible employees; with orthodontia? ❑ Yes ❑ No ❑ 3 to 9 eligible employees (orthodontia not available) ❑ Voluntary Dental ❑ Voluntary Vision - select one ❑ 12/12/12 ❑ 12/12/24 ❑ Voluntary Accident & Illness Benefits Additional No-cost Services Separate forms are required to set up each of these services. ❑ Short-term Disability* - select one ❑ Group ❑ Voluntary ❑ Long-term Disability* - select one ❑ Group ❑ Voluntary Note: LTD is not available to employees who work fewer than 30 hours per week. ❑ CBIA COBRA Administration ❑ CBIA HRA Administration * If electing STD or LTD coverage an original completed Tax Service Agreement must be submitted. Separate Tax Service Agreements are required if electing both STD and LTD coverage. ❑ Identity Theft Protection ❑ Employer paid ❑ Gold ❑ Platinum ❑ Employee only ❑ Employee & family ❑ Employee paid RETIRED EMPLOYEES—A retired employee is defined as a former employee who is age 65 or older and worked for your company as a full time employee for a minimum of 10 years and was retired by your company. Coverage is not available to retirees under age 65. Are you selecting retiree coverage? ❑ Yes ❑ No Check the retiree group you are selecting coverage for: ❑ Existing and future retired employees ❑ Existing only ❑ Future only Check all the retiree coverages you are applying for: ❑ Medical ❑ Dental ❑ Group Basic Life (AD&D discontinued at retirement) ❑ Voluntary Dental ❑ Voluntary Vision Retirees are only eligible for coverage in Medicare plans offered in CBIA Health Connections. 6 AGENT INFORMATION I designate Agent of Record as: Address (Street) Address (City, State, ZIP Code) Agency The undersigned agent attests they are individually, and the applicable commissionable agent, are duly licensed and have the required training and appointments with the appropriate government agency, authority, and carrier(s) to solicit enrollment of qualified employees or former employees of an employer participating in CBIA Health Connections and also specifically into a Medicare Advantage with Prescription Drug “MAPD” Plan. The agent of record repr...
BENEFIT ELECTIONS. To the extent that Graduate Workers are eligible to elect benefits, the University will ensure that there will be sufficient enrollment opportunities to do so.
BENEFIT ELECTIONS. The form of payment of Executive's Normal Retirement Benefit, Disability Benefit and Change of Control Benefit in effect on December 31, 2007, on the Form of Benefit Election attached as Exhibit II to the Agreement is irrevocable as of December 31, 2007, and may not be subsequently changed except in accordance with the following restrictions:
BENEFIT ELECTIONS. A copy of the sold proposal for Life and Disability benefits must be signed and attached. ❑ Group Basic Life ❑ Contributory ❑ Non-contributory ❑ Voluntary Life ❑ Voluntary Dependent Life ❑ Voluntary Dental ❑ Voluntary Vision - select one ❑ 12/12/12 ❑ 12/12/24 ❑ Short-term Disability* - select one ❑ Group ❑ Contributory ❑ Non-contributory ❑ Voluntary ❑ Long-term Disability* - select one ❑ Group ❑ Contributory ❑ Non-contributory ❑ Voluntary Note: LTD is not available to employees who work fewer than 30 hours per week. Additional No-cost Services Separate forms are required to set up each of these services. ❑ CBIA COBRA Administration ❑ CBIA Healthy Connections Wellness Program * If electing STD or LTD coverage an original completed Tax Service Agreement must be submitted. Separate Tax Service Agreements are required if electing both STD and LTD coverage.
BENEFIT ELECTIONS. 36 7.04 Distributions Under Domestic Relations Orders ............... 37 7.05
BENEFIT ELECTIONS. Not earlier than 90 days, but not later than 30 days, before a Participant's or Beneficiary's Annuity Starting Date, the Plan Administrative Committee must provide a benefit notice to a Participant or Beneficiary who is eligible to make an election under Section 7.01. The benefit notice must explain the form of benefit distribution available under the Plan and the Participant's or Beneficiary's right to defer distribution. If a Participant or Beneficiary makes a valid election prescribed by this Section 7.03, the Plan Administrative Committee shall direct the Trustee to distribute the Participant's Nonforfeitable Accrued Benefit in accordance with the election. The Participant or Beneficiary must make an election under this Section 7.03 by filing his election form with the Plan Administrative Committee before the Trustee otherwise would commence to pay a Participant's Accrued Benefit in accordance with the requirements of this Article VII.
