| CareBasic Staffing |
PLAN 1 - CHANGE FORM |
2964501 |
| Mail / Fax to: |
Planned Administrators, Inc.
PO Box 6702
Columbia, SC 29260 |
Telephone (866) 798-0803
Fax (803) 264-0772 |
Underwritten by
BCS Insurance Company
Oakbrook Terrace, IL |
Fill out this form ONLY if you are making changes in your coverage or terminating coverage.
| MUST BE FILLED OUT |
Address/Name Change |
|
Name
|
Social Security #
|
Phone
|
Gender
|
|
Address
|
City
|
State
|
Zip
|
Apt. #
|
|
Employer
|
Hire Date
|
Date of Birth
|
| Add/Change Dependent Information |
| |
You MUST enroll in the Fixed Indemnity Medical Insurance Plan before adding any additional benefits in Section C.
Your coverage level for the additional benefits in Section C will be identical to your Fixed Indemnity Medical Plan selection. |
| |
FIXED INDEMNITY
MEDICAL 1 |
DENTAL 1 |
VISION 1 |
TERM LIFE 1 |
SHORT-TERM
DISABILITY 1,2 |
| Employee Only |
$22.76 |
$5.40 |
$2.42 |
$0.60 |
$4.20 |
| Employee + Child(ren) |
$37.78 |
$14.58 |
$6.54 |
$0.90 |
|
| Employee + Spouse |
$43.24 |
$10.80 |
$4.84 |
$0.90 |
|
| Employee + Family |
$57.58 |
$20.52 |
$9.20 |
$1.80 |
|
| |
Terminate Plan |
Enroll |
Enroll |
Enroll |
Enroll |
| |
No Change |
Cancel |
Cancel |
Cancel |
Cancel |
| |
|
No Change |
No Change |
No Change |
No Change |
| Selected |
|
|
|
|
|
| Add/Change Life/Accidental Loss of Life, Limb and Sight Beneficiary |
| Primary |
|
Relationship |
|
| Secondary |
|
Relationship |
|
| MEC Wellness/Preventive 1 Terminate MEC Plan | No Change |
| $58.19 Employee Only | $65.79 Employee + Child(ren) | $71.00 Employee + Spouse | $80.87 Employee + Family |
| Selected |
|
| I hereby authorize my employer to deduct the required premium contributions from my payroll earnings. I understand that deductions may continue under my old elections until this form is received and processed by PAI. Deductions will not be refunded, however, coverage will continue as long as you have a paycheck deduction. I understand that making no selection in Section C and D for a benefit means I do not wish to make a change to that benefit. |
Form: CBS/MEC P1M v26.1
