Beruflich Dokumente
Kultur Dokumente
Fishing, LLC
Premium Election Form | 2015
Correction
Change of personal information
Change of Family Status
Transfer
Effective Date_________
Termination
Waive Participation _____ (initial)
Personal Information
Last Name
First Name
Middle Initial
Home Address
Street
City
State
Zip
_________________________________________________________________________________________________________
Date of Birth:
/ /
Benefit Elections
For employees who are currently enrolled, your 2014 enrollment elections will automatically roll over to 2015 at the new
rates below. If you wish to enroll or make changes, please circle the 2015 rates for the coverage you select. For all
employees continuing coverage, add up the amounts and enter the total on Total Cost per Trip. Sign, date, and return this
form to Courtney Banks at the office before February 20th, 2015.
Coverage
Benefit Year
Vol. Health
Employee Only
2015
$213.00
Vol. Dental
$37.53
$79.20
$104.20
$153.88
Vol. Vision
$8.01
$12.82
$13.09
$21.10
______________________________________________
Employee Signature
_______________________
Date
______________________________________________
Company Representative
_______________________
Date