Optional Dental. ❑ Dental 750 ❑ Dental 1000 ❑ Dental 1500 Dental 2000 ❑ Dental 2500 ❑ Decline ❑ Voluntary (Employee paid. Must have ❑ minimum 2 employees enrolled Orthodontia: ❑ Yes ❑ No (Available to groups of 10+. Voluntary Plan not eligible.) Vision: ❑ Exam Plus ❑ Basic ❑ Preferred ❑ Enhanced ❑ EasyOptions ❑ Decline Basic Life/AD&D (Life plan required with all medical plans): 100% employee participation ❑ Plan A ($25,000) ❑ Plan B ($50,000) ❑ Plan C ($100,000) ❑ Plan D ($250,000)
Optional Dental. Orthodontia (Available to groups of 10+): q q q Dental 750 Dental 1000 Yes q q q Dental 1500 Dental 2000 No q q Dental 2500 Decline Vision: q Exam Plus q Basic q Preferred q Enhanced q EasyOptions q Decline Basic Life/AD&D (Life plan required with all medical plans): 100% employee participation q Plan A ($25,000) q Plan B ($50,000) q Plan C ($100,000) q Plan D ($250,000) Supplemental Life and AD&D: q Yes q No (No minimum employee participation requirement) Short Term Disability: q Yes (salary info required) q 26-week duration q 13-week duration q No 100% employee participation: 60% of weekly salary. All plans Non-Contributory. q STD Plan 1: $2500 wkly benefit; 0/7 Day Elimination Period q STD Plan 2: $2000 wkly benefit; 7/7 Day Elimination Period q STD Plan 3: $ 1750 wkly benefit; 7/7 Day Elimination Period q STD Plan 4: $1250 wkly benefit; 14/14 Day Elimination Period Long Term Disability: q Yes (salary information required) q 180-day EP q 90-day EP q No 100% employee participation: 60% of weekly salary; 180-day EP, 90-day EP Option if Stand-alone. All plans Non-Contributory. q LTD Plan 1: $10,000 max; Benefit to SSNRA q LTD Plan 2: $8,000 max; Benefit to SSNRA q LTD Plan 3: $6,000 max; Benefit to SSNRA q LTD Plan 4: $5,000 max; 5-Year Benefit Duration 3 visits included in medical plan A membership with WTIA is required to obtain coverage through WTIA Employee Benefit Trust. Please submit the WTIA Membership Application along with dues payment. Membership must be maintained to continue coverage under the plan. Membership fees are not used to provide plan benefits and are not consider plan assets. Any membership fees received by the WTIA Employee Benefit Trust will be forwarded to the WTIA. Current Member: q Yes q No Late Fee Policy – Premiums are due by the 1st day of the coverage month. Late payments will be assessed a late fee of 5% of the amount owed. The fee will be added to the next month’s billing statement. Unpaid balances may be referred to collections. The employer will be responsible for any fees, attorney fees or other fees, associated with the collections process. Payment Options: q Electronic Funds Transfer (EFT) (You must fill out the EFT form) q Online q Check q Yes q No FMLA: Did your company employ 50 or more full and/or part-time employees during each of the 20 calendar weeks in the current or preceding calendar year, and is it subject to federal TEFRA laws? Affordable Care Act Required Information: Please enter the average number of emp...
Optional Dental. ☐ DHMO High ☐ PPO 50-1500 A2 Optimum ☐ PPO 50-1500 P290 O ☐ PPO 50-1000 A Value ☐ PPO 25-2000 A2 Optimum ☐ PPO 50-1000 A90 V ☐ PPO 50-1500 A Value w/ 1500 Adult and Child Ortho ☐ Decline Groups of 10 or more enrolled employees may select up to 2 dental plans, one of which must be the DHMO High plan option. Vision: ☐ Exam Plus ☐ Basic ☐ Preferred ☐ Enhanced CVC ☐ EasyOptions ☐ Decline Basic Life/AD&D (Life plan required with all medical plans): ☐ Plan A($25,000) ☐ Plan B($50,000) ☐ Plan C($100,000) ☐ Plan D($250,000) Supplemental Life and AD&D: ☐Yes ☐No (Nominimumemployee participationrequirement) Short Term Disability: ☐ Yes(salaryinforequired) ☐ 26-weekduration ☐ 13-weekduration ☐ No 100% employeeparticipation: 60% of weeklysalary. Allplans Non-Contributory. ☐ STD Plan 1: $2500 wkly benefit; 0/7 Day Elimination Period ☐ STD Plan 2: $2000 wkly benefit; 7/7 Day Elimination Period ☐ STD Plan 3: $ 1750 wkly benefit; 7/7 Day Elimination Period ☐ STD Plan 4: $1250 wkly benefit; 14/14 Day Elimination Period Long Term Disability: ☐ Yes (salary information required) ☐ 180-day EP ☐ 90-day EP ☐ No 100% employee participation: 60% of weekly salary; 180-day EP, 90-day EP Option if Stand-alone. All plans Non-Contributory. ☐ LTD Plan 1: $10,000 max; Benefit to SSNRA ☐ LTD Plan 2: $8,000 max; Benefit to SSNRA ☐ LTD Plan 3: $6,000 max; Benefit to SSNRA ☐ LTD Plan 4: $5,000 max; 5-Year Benefit Duration A membership with AZTC is required to obtain coverage through AZTC Employee Benefit Trust. Please submit the AZTC Membership Application along with dues payment. Membership must be maintained to continue coverage under the plan. Membership fees are not used to provide plan benefits and are not considered plan assets. Any membership fees received by the AZTC Employee Benefit Trust will be forwarded to the AZTC. AZTC does not condition membership in the Association or participation in the Trust on any health status-related factor relating to an individual. Current Member: ☐ Yes ☐ No Late Fee Policy – Premiums are due by the 1st day of the coverage month. Late payments will be assessed a late fee of 2% of the amount owed. The fee will be added to the next month’s billing statement. Unpaid balances may be referred to collections. The employer will be responsible for any fees, attorney fees or other fees, associated with the collections process. NEW GROUPS – A binder check is not required for groups that elect EFT for payment.
Optional Dental. ❑ Dental 750 ❑ Dental 1000 ❑ Dental 1500 ❑ Dental 2000 ❑ Dental 2500 ❑ Decline Orthodontia (Available to groups of 10+): ❑ Yes ❑ No Vision: ❑ Exam Plus ❑ Basic ❑ Preferred ❑ Enhanced ❑ EasyOptions ❑ Decline ❑ Plan A ($25,000) ❑ Plan B ($50,000) ❑ Plan C ($100,000) ❑ Plan D ($250,000)
Optional Dental. ❑ Dental 750 ❑ Dental 1500 ❑ Dental 2500 ❑ Dental 1000 ❑ Dental 2000 ❑ Decline Orthodontia (Available to groups of 10+): ❑ Yes ❑ No Vision: ❑ Exam Plus ❑ Basic ❑ Preferred ❑ Enhanced ❑ EasyOptions ❑ Decline
Optional Dental. ❑ Plan 1 ❑ Plan 2 ❑ Plan 3 ❑ Plan 4 ❑ Decline Orthodontia (Available to groups of 10+): ❑ Yes ❑ No Vision: ❑ Exam Plus ❑ Basic ❑ Preferred ❑ Enhanced ❑ Decline
