Enrollment Form - SDRMA - 2009-07-06 Ancillary Coverages SDRMA
Entity Enrollment Form
ENTITY INFORMATION—The Entity applicant certifies the following information:
Entity's Legal Name:
O s- ff1 t°S G JG r1 -I-Cie"
Street Address: City: State: Zip:
(4+D-8 W t 1-t-, SA- . �.c s 1-✓� ,M�s ,� C: ft1 �t 2 C. 2-1-
County:
Q a S e C (3,
Contact Name: Title: Phone Number: ti Fax Number.
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(j,50
Email:
Sk�ttt� e c.-�sdc �, . 3O
Form of Organization:
[government Entity(non-schools) ❑School(non-JPA) ❑JPA ❑Other
•
COVERAGE(S) REQUESTED AND CONTRIBUTIONS The Entity selects the following coverages to be available for the employees and
will contribute the following percentage of the subscription charge/premium on behalf of its employees for the coverage(s)requested below:
' Base�Paackge (Required) Optional Coverages Available
{Choose el#her planor both) (Mandatory that•these coverages are paid by the Employer; except for
‘„* Supplemental Life) y �
❑ Delta Dental ❑ Vision Service Plan 141.,ING Basic Life and I ING LTD MHN Employee
AD&D Long Term Disability Assistance Program
Entity contributes the Entity contributes the
following%toward following%toward Select One Plan Below: Select One Plan Below:
premium cost: premium cost:
8-10+Lives '®, 10+Lives
Employee % Employee % ❑ Less than 10 Lives ❑ Less than 10 Lives
Dependent % Dependent % Please list life insurance amount Please list annual salary on
on Participant Enrollment Form Participant Enrollment Form
Select One Plan Below For Select One Plan Below For
All Employees: All Employees: The life insurance amount must Select One Option Below:
be the same for all employees in
❑ Low Plan ❑ Option 1 Plan A that class or bargaining unit ID Option 1-90 days
❑ Medium Plan ❑ Option 2 Plan B ❑ We intend to make ❑ Option 2-180 days
❑ High Plan ❑ Option 3 Plan B Supplemental Life available
❑ Option 4 Plan C to our employees
❑ Option 5 Plan C
EMPLOYEE ELIGIBILITY
Eligible employees are: E Active full-time benefit eligible employees who work at least 30 hours per week
Part-time benefit eligible employees working at least 20 hours per week
Total number of employees: t Total number of employees ineligible:
Total number of active full-time eligible enrolling employees: ` Total number of part-time or temporary employees: sk
PROBATIONARY PERIOD/ELIGIBILITY DATE:
Eligibility Date is always on the FIRST DAY of the month following waiting period unless otherwise specified.
The waiting period for new employees: ❑one month ❑two months ❑three months ❑Other
❑Other than FIRST DAY of month: Eligible on day from ❑date of hire or ❑Other
Special District Risk Management Authority Page 1 of 2 Toll-Free 800.537.7790
Fax 916.231.4111
www.sdrma.org
•
PUBLIC OFFICIALS/GOVERNING BODY
For Public Officials/Governing Body members to be covered under SDRMA Ancillary Coverages the Public Officials/Governing Body members must
currently be covered through the Entity's existing ancillary coverages.
Check here❑ If you intend to continue providing ancillary coverages to your Public Officials/Governing Body members through SDRMA Ancillary
Coverages.
Total number of public officials:
Total number of enrolling public officials:
DOMESTIC PARTNERS
Standard coverage for the domestic partner of an employee or subscriber to the same extent, and subject to the same terms and conditions, as
provided to a dependent of the employee or subscriber.Coverage of the employee's/subscriber's domestic partner requires submission of a certified
copy of a Declaration of Domestic Partnership, or similar form, filed with the State of California or another governing jurisdiction. Both domestic
partners must be at least 18 years of age.Coverage is extended to the children of the domestic partner. There are no COBRA continuation rights for
the domestic partner or the domestic partner's children.
CURRENT CARRIER(S):
Is this plan intended to replace any existing group coverage? al YES ❑NO
If YES,name of group carrier(s): � v o.� e_R-
Current group carrier proposed termination date: ' U_'.,9._
GENERAL AGREEMENT AND SIGNATURE
Effective date requested: / l 0 • (Actual date will be assigned by SDRMA if application is accepted)
Application is hereby made to SDR1�A or he appropriate affiliated company for a Group Benefit Agreement/Group Policy providing coverage
identified above. If this application i"s accepted, an Agreement/Policy will be issued which will set forth the terms, benefits and conditions of the
relationship between the Entity and SDRMA. This application will become part of that Agreement/Policy.
Upon acceptance of the application,the Entity will inform all persons who are eligible for coverage that they may apply for SDRMA coverage under
the Agreement/Policy.
I understand and agree to all of the above.
Date: / (c> 0yc1 Ma .cye ..�
By: ,� cal Name and Title: 7�e f rj ���(O V �c3
(Authorized Sigrkdture) (Print Name and Title of Authorized Signer)
13. FOR SDRIYI ):U.,s'E QNLY
Application is: ❑Accepted ❑Declined Case No.
Effective: Underwriter: Date:
Date: By:
(Signature)
(rev.09/20/07)
Special District Risk Management Authority Page 2 of 2 Toll-Free 800.537.7790
Fax 916.231.4111
www,sdrma,org
SDRMA Life & Disability
New Case Information Sheet
Entity Name: Cos4-6, e ^ ,.1.r&r15
Number of Covered Employees:
❑ Less than 10 X 10 or more
Please answer the
AfolloWing questions
What is your definition of an eligible employee? (i.e. active employee who works 32
hours per week) c, c4_, �c p(oe c_ ho w2\CS yv tr.r.S
p e.elL
What is your benefit waiting period? (Explanation: the period of time an employee has
to wait before he/she is eligible for the insurance coverage. I.e. 30 days of
continuous service) ct o d S
Please,answer the
fol owing questions if E
customer has,'Disability s
Employees Participate in SDI n Yes , No
FICA contribution includes Social Security ❑ Yes LJ No
Do you want ING to provide W-2 Services ❑ Yes [X No
Are Disability premiums paid on a Pre or Post N.,Pre Tax
tax basis? Post Tax
Basic Life:
Benefit Level Class Definition
$10,000 ❑ Yes,❑ No
$20,000 ❑ Yes [7 No
$30,000 Yes ❑ No
$40,000 ❑ Yes ❑ No
$50,000 X Yes ❑ No a t l e m<p(o ce s
• $60,000 ❑ Yes ❑ No
$70,000 ❑ Yes I I No
$80,000 ❑ Yes ❑ No
$90,000 ❑ Yes ❑ No
100,000 ❑ Yes ❑ No
lx Salary Option ❑ Yes ❑ No
2x Salary Option ❑ Yes ❑ No
Supplemental Life:
❑ Yes g] No
• In 6rd to elect Supplemental Life coverage, groups must also elect Basic Life coverage
LTD:
Option 1: 90 Day Elimination Period ❑ Option 2: 180 Day Elimination Period