CareBasic Staffing Plan 1 - Change Form A.REASON FOR THE CHANGE(Required) Address Change Name Change Add Dependent(s) Coverage Change Terminate Coverage B.REQUIRED EMPLOYEE INFORMATIONMUST BE FILLED OUTName(Required)Phone(Required)Email(Required) Social Security #(Required)Gender(Required) Male Female Address(Required)City(Required)State(Required)Zip(Required)Apt. #Employer(Required)Hire Date(Required) MM slash DD slash YYYY Date of Birth(Required) MM slash DD slash YYYY Add/Change Dependent InformationDependentsNameSocial Security #Date of BirthGenderRelationship Add RemoveC.INDEMNITY PLAN CHANGES - Select the change you wish to make for each benefit (Weekly rates)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 INDEMNITYMEDICAL 1 DENTAL 1 VISION 1 TERM LIFE 1 SHORT-TERMDISABILITY 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 1 This coverage is not available to residents of NH, HI, or PR. 2 STD is not available to persons who reside in CA, HI, NH, NJ, NY, or RI. FIXED INDEMNITY MEDICAL Employee Only Employee + Child(ren) Employee + Spouse Employee + Family Terminate Plan No Change DENTAL Enroll Cancel No Change VISION Enroll Cancel No Change TERM LIFE Enroll Cancel No Change SHORT-TERM DISABILITY Enroll Cancel No Change Add/Change Life/Accidental Loss of Life, Limb and Sight BeneficiaryPrimaryRelationshipSecondaryRelationshipD.MEC PLAN CHANGES - Select the change you wish to make. (Monthly Rates)82964501MEC 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 1 This coverage is not available to residents of HI, or PR.AuthorizationI 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.Date(Required) MM slash DD slash YYYY Signature(Required)
