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AlwaysCare Vision Insurance Enrollment

  • Underwritten by National Guardian Life
    Insurance Company
    Administered by: Starmount Financial Corporation
    PO Box 98100
    Baton Rouge, LA 70898-9100
  • AlwaysCare Employee Benefits

    Vision Insurance
    Enrollment Form

  • EMPLOYEE INFORMATION

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Family Information (CHILDREN COVERED UP TO AGE 26)

  • 1st Family Member

  • Date Format: MM slash DD slash YYYY
  • 2nd Family Member

  • Date Format: MM slash DD slash YYYY
  • 3rd Family Member

  • Date Format: MM slash DD slash YYYY
  • 4th Family Member

  • Date Format: MM slash DD slash YYYY
  • 5th Family Member

  • Date Format: MM slash DD slash YYYY
  • 6th Family Member

  • Date Format: MM slash DD slash YYYY
  • I elect the following vision coverage:

  • Enrollment in this plan is binding under Section 125 of the Internal Revenue Service Code, which makes it possible for employers to offer their employees a choice of non-taxable benefits. After a participant has elected and begun to receive benefits under the plan, the plan may not allow the participant to revoke or make changes to the benefit election unless one of the following rules apply: Under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), group health plans are required to permit eligible employees to enroll for coverage following the loss of other health coverage or if a person becomes an eligible spouse or dependent of an eligible employee through birth, marriage, adoption, or placement for adoption. In addition, under the Change in Status rules, a plan may permit participants to revoke or make change to a benefit election if a change in status occurs and the election change is “consistent” with the change in status. Those rules apply to a change in employment status, cases where a dependant satisfies or ceases to satisfy the requirements of eligibility, judgment, decree or order and entitlement to Medicare or Medicaid.
  • Date Format: MM slash DD slash YYYY
  • Acceptance or declination of coverage must be confirmed by employee’s signature above.
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