ࡱ> QTNOPs zbjbj2)2) :PCfPCfK*_r r 8PD];X ####&%'(9999999$A>@^9(&%&%((9##4:L222(F##92(922n22#?j(29;H];2UAd)$UA22UA"3h((2(((((99-~(((];((((UA(((((((((r X : Associated Employers Health Trust Employee Enrollment & Change Form 20201. GROUP INFORMATION (to be completed by the group) Please Be Sure To Fill Out All SectionsCompany Name:  FORMTEXT      Effective Date:  FORMTEXT       Date of Hire:  FORMTEXT       Rate of Pay and Amount: $  FORMTEXT       per  FORMCHECKBOX  Yr  FORMCHECKBOX  Mo  FORMCHECKBOX  Bi-Wk  FORMCHECKBOX  Wk  FORMCHECKBOX  Hr Hours worked per week  FORMTEXT        FORMCHECKBOX  New  FORMCHECKBOX  Change (Mark Reason Below) COBRA CARRY-OVER ELECTION MUST USE COBRA CARRYOVER APPLICATION TO ENROLL.  FORMCHECKBOX  Hire/Rehire  FORMCHECKBOX  Open Enrollment  FORMCHECKBOX  Loss of Prior Coverage  FORMCHECKBOX  Address/Name Change  FORMCHECKBOX  Add or  FORMCHECKBOX  Remove Dependent(s) Effective Date of Change: FORMTEXT       Reason  FORMTEXT        FORMCHECKBOX  Termination: Last day Worked  FORMTEXT       Last day Compensated  FORMTEXT       Date Coverage Ends  FORMTEXT        FORMCHECKBOX Voluntary  FORMCHECKBOX Involuntary of Coverage2. EMPLOYEE INFORMATION (employee to complete sections 2 through 5) Please print legibly and sign ApplicationEmployee Name: (Last, First, MI)  FORMTEXT       Social Security #:  FORMTEXT       -  FORMTEXT    -  FORMTEXT     Date of Birth:  FORMTEXT       Gender:  FORMCHECKBOX  Male  FORMCHECKBOX  Female FORMCHECKBOX  Married  FORMCHECKBOX  UnmarriedHome Phone: ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     Worksite Location (State):  FORMTEXT     Mailing Address: City State Zip  FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      Employee Email Address:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      3. ENROLLMENT INFORMATION: Please note that an incomplete application may delay processing. Please make sure to print legibly and sign application. By providing your email address, you are agreeing to receive plan documents via electronic delivery. FORMCHECKBOX  I choose to WAIVE dental coverage.  FORMCHECKBOX  I choose to WAIVE vision coverage.Dental Plan Choice (Underwritten by Delta Dental of Washington): Only available if chosen by your employer.  FORMCHECKBOX  I choose to ELECT dental coverage. Plan Selection:  FORMTEXT       (Your employer has selected the options available to you. See your benefit administrator for details.)Vision Plan Choice (Underwritten by VSP Vision Care Inc.): Only available if chosen by your employer.  FORMCHECKBOX  I choose to ELECT vision coverage. Plan Selection:  FORMTEXT       (Your employer has selected the options available to you. See your benefit administrator for details.)Supplemental Employee and Dependent Life and AD&D Underwritten by Standard Insurance Company (Only available if chosen by your employer) Supplemental Employee Life/AD&D coverage.  FORMCHECKBOX  Yes  FORMCHECKBOX  No IF YES for Employee Coverage: Supp Dependent Life/AD&D for Spouse Only  FORMCHECKBOX  Yes  FORMCHECKBOX  No Supp Life for Dependent Child(ren)  FORMCHECKBOX  Yes  FORMCHECKBOX  No Amount of Coverage Requested (Please see your benefit administrator for allowed increments) Employee: FORMTEXT       Spouse:  FORMTEXT       NOTE: In order for dependents to qualify for a benefit selection, the employee must select the same benefit. Please indicate each member s name as you would like it to appear on the ID Card. If a dependent has a separate mailing address, please attach.AddDropRelationshipLast NameFirst NameMISocial Security No.Date of BirthGenderBenefit SelectionMFDentalVision FORMCHECKBOX  FORMCHECKBOX Spouse  FORMCHECKBOX  Domestic Partner  FORMCHECKBOX * FORMTEXT       FORMTEXT       FORMTEXT   FORMTEXT     -  FORMTEXT    -  FORMTEXT      FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT   FORMTEXT     -  FORMTEXT    -  FORMTEXT      FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT   FORMTEXT     -  FORMTEXT    -  FORMTEXT      FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT   FORMTEXT     -  FORMTEXT    -  FORMTEXT      FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT   FORMTEXT     -  FORMTEXT    -  FORMTEXT      FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT   FORMTEXT     -  FORMTEXT    -  FORMTEXT      FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX For individuals who are eligible for enrollment in an employer group health plan: If you are declining enrollment for yourself or your dependents (including your spouse/domestic partner) because of other health insurance or employer group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if, in the case of employer group health plan coverage, the employer stops contributing toward you or your dependents other coverage.) However, you should request enrollment within 60 days after you or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you gain a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you should request enrollment within 60 days of the marriage, birth, adoption, or date of assumption of total or partial legal obligation for support of a child in anticipation of adoption. Dependents are not required to reside with the subscriber. Dependents are not required to be dependent upon the subscriber for support. Eligibility for medical assistance is not considered when determining eligibility for coverage or making payments. Dependent children are eligible for coverage through the age of 25 regardless of marital status, student status or eligibility for coverage under another plan. 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If children of the primary insured are covered, children of Domestic Partners are eligible for coverage on the same basis. 4. DESIGNATION OF BENEFICIARY- Mandatory to complete for designation of benefit provided with ALL Life ProductsEMPLOYEE BENEFICIARY:Primary Beneficiary Name and Relationship* for Basic life/AD&D & Supp. Life/AD&D  FORMTEXT      Primary Beneficiary Address  FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      EMPLOYEE BENEFICIARY:Contingent Beneficiary Name and Relationship** for Basic life/AD&D & Supp. Life/AD&D  FORMTEXT      Contingent Beneficiary Address  FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      * If more than one primary beneficiary is named, the primary beneficiaries shall share equally unless otherwise indicated above. ** Contingent Beneficiary(ies) will only receive proceeds if all Primary Beneficiaries have predeceased the Insured. If you are naming more than one Contingent Beneficiary at 100% each, please indicate them in order of precedence.5. SIGNATUREI hereby apply for enrollment or change of enrollment as indicated on this application. I understand that the Trust and the Health Carriers or Insurers may collect, use and disclose protected health information about each individual enrolled under this application in order to carry out their routine business functions, including but not limited to, determining eligibility for benefits, paying claims, coordinating benefits with other insurance carriers or payer, underwriting and conducting case management care management and quality reviews. The Trust and the Health Carriers and Insurers may also disclose protected health information to state and federal agencies, or other third parties, as required by law. I understand that information collected in connection with administration of the benefit plan may be used to bring to my attention health products or services that might be valuable to me and otherwise as permitted by law. I agree to accept and/or access all plan documents and notices via electronic delivery. My consent can be withdrawn at any time, without charge. In order to withdraw or obtain a paper version of any document or notice, I will send a written request to AIMS, at the address listed below. I understand that the benefit plan that I have selected provides reimbursement for certain costs, which are more fully described in the current Certificate of Coverage. I understand there may be instances where treatment decisions made by my physician or me or expenses which I have incurred may not be covered by my benefit plan. The undersigned understands that it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of coverage or other insurance benefits. The changes on this form supersede all previous forms submitted. I authorize my employer to deduct from my earnings the amount, if any, for the coverage selected. Please note: Incomplete applications will delay processing.Employee Signature (required) Date:  FORMTEXT      Employer Signature (required) Date:  FORMTEXT        Please return form to: AIMS 1206 North Lincoln, Suite 200 Spokane, WA 99201-2559 fax to: (509) 777-2690 or email to  HYPERLINK "mailto:aims@aiin.com" aims@aiin.com Standard Insurance Company 920 SW 6th Avenue Portland, OR 97204Delta Dental of Washington 400 Fairview Ave N #800 Seattle, WA 98109VSP, Vision Care Inc. 3333 Quality Dr. Rancho Cordova, CA 9567Magellan Health Services 14100 Magellan Plaza Drive MO-10 Maryland Heights, MO 63043     Services and Access provided by AIMS 2020 11.12.2019 Employee Enrollment Form &(TZyppUF ' $Ifgdt  L00$IfXDYDgdD $Ifgdx` $IfgdDxkd$$Ifl6;  t 0;44 la4p yti VXZ\prtvxz|~첲ݣݍ}}}}}g}}}}}+j9hihx`CJOJQJUaJjhtCJOJQJUaJ+jhihx`CJOJQJUaJhihDCJOJQJaJ(jhihx`CJUaJmHnHu+jIhihx`CJOJQJUaJhihx`CJOJQJaJ%jhihx`CJOJQJUaJ& "PzַƤo_ַI+j8hihx`CJOJQJUaJh\8hx`5CJOJQJaJhihx`5CJOJQJaJ+j)hihDCJOJQJUaJhihDCJOJQJaJ%jhihDCJOJQJUaJhihx`CJOJQJaJjhtCJOJQJUaJ%jhihx`CJOJQJUaJ+jhihx`CJOJQJUaJ"6re\\MM ' $IfgdD $Ifgdx` $IfgdDkd$$Ifl4FG60;    4 la4f4yt\8468LNPRTVXZ\^`tvxz|~ɺiiiiiSiiiii+j(hihDCJOJQJUaJ0jhihDCJOJQJUaJmHnHu+jhihDCJOJQJUaJ%jhihDCJOJQJUaJhihCJOJQJaJhihDCJOJQJaJhihx`CJOJQJaJ%jhihx`CJOJQJUaJ(jhihx`CJUaJmHnHu ȯȯȊ}}m[F[(h hD5B*CJOJQJaJph"h\85B*CJOJQJaJphhihx`5CJOJQJaJh\}Khx`CJOJQJhihx`CJOJQJaJ+jhihDCJOJQJUaJ0jhihDCJOJQJUaJmHnHu%jhihDCJOJQJUaJ+jhihDCJOJQJUaJhihDCJOJQJaJrcdx$If[$gd? kd$$Ifl4FG60;    4 la4f4yt\800$IfXDYDgd\8fkd'$$Ifl46;0;4 la4f4yt/0X ^`Z<°|paO" *h h 5CJOJQJaJh h CJOJQJaJh$YCJOJQJaJhrhD]5CJOJQJaJ" *hD]hD]5CJOJQJaJ" *hD]h? 5CJOJQJaJ" *hrh? 5CJOJQJaJh? 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