2022 Benefits Election Form – GRBS Employee Portal GRBSTOOLS

Benefits Election Form (2022)

Benefits Waiver*
Medical / Dental / Vision / Life / Dependent Flex Spending
*you can select any, all or none
- I decline ALL benefits
- I will choose my benefits below
Please let us know why you are declining:
- Spousal Coverage
- Covered By Other Insurance
- Prefer Individual Health Plan
- Too Expensive
Name*
First Middle Last
Gender
- M
- F
S.S.N.
Date of Birth
Month
Day
Year
Address
Address City State Zip
Hidden
County
Primary Phone*
Email (for confirmation)
Job Title
Employee PIN*
District
Date of Hire
Month
Day
Year
Marital Status
- Single
- Married
- Divorced
I wish to change my current elections due to a Qualifying Life Event
Leave blank if applying for benefits for the first time.
- Marriage/Divorce
- Birth/Adoption
- Death
- Ineligible Dependent
- Change in Spouse Employment
- Other
Benefit Elections
(Premium amounts are per by-weekly paycheck)
Is your district Birmingham?
- No
- Yes
Medical/Rx - Priority Health
3 Prices based on income per hour: <$12 / $12-$13.49 / $13.50+
Medical/Rx - Priority Health (Birmingham)
Dental - Ameritas
Vision - Ameritas (VSP Network)
Accident (Unum)
Short-Term Disability (Unum)
Rate Calculation Table
- I elect coverage for myself
- I decline Short-Term Disability
Critical Illness (Unum) (Spouse amount limited to 50% of employee election)
Rate Calculation Table
- I elect coverage for myself
- I elect coverage for myself and my spouse
- I decline Critical Illness Coverage
Choose Critical Illness Benefit Level For Self
- $10,000
- $20,000
- $30,000
Choose Critical Illness Benefit Level For Spouse
- $5,000
- $10,000
- $15,000
VOLUNTARY LIFE AND AD&D INSURANCE | UNUM*
CLICK HERE FOR RATE CHART
- I elect coverage for myself
- I elect coverage for my spouse
- I elect coverage for my child(ren)
- I would like to continue my current Voluntary Life and AD&D Coverage as is
- I decline voluntary life and AD&D coverage
In the amount of
coverage for myself
Rate per pay (see chart)
coverage for myself
In the amount of
coverage for my spouse
Rate per pay (see chart)
coverage for my spouse
In the amount of
coverage for my child(ren)
Rate per pay (see chart)
coverage for my child(ren)
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) | Basic*
- I elect to participate.
- I decline to participate in the Dependent Care (FSA) Account
I elect this annual amount
(not to exceed $5,000 or $2,500 if married filing separately)
The annual amount you elect to contribute will be deducted evenly from your regularly scheduled paychecks.
Please enter a number less than or equal to 5000.
Reimbursement Options:
- Direct Deposit
- No Direct Deposit
Financial Institution (Name of Bank)
Account Type
- Checking
- Savings
Routing Number (9 digits)
Account Number
Dependent and Beneficiary Information
LIST ALL DEPENDENTS TO BE COVERED:
DOCUMENTATION IS NEEDED FOR ADOPTED / FOSTER / STEP CHILDREN OR SPOUSE WITHOUT THE SAME INSURED NAME (Click on the "+" to add additional dependents)
Name (Last, First, MI) Date of Birth (MM/DD/YYYY) Gender Social Security Number Relationship
Are any of these dependents IRS Disabled Dependents?
- No
- Yes
If Yes, Dependent Name:
Are all / any of the dependents at an alternate address?
- No
- Yes
If Yes, Dependent Address:
LIFE INSURANCE BENEFICIARY INFORMATION
a beneficiary is the person (or entity) who will receive the cash benefit from your life insurance policy if you die
Primary / Contingent Name (Last, First, MI) Date of Birth (MM/DD/YYYY) Gender (M/F) Social Security Number Relationship Annual Income %
SALARY REDUCTION AGREEMENT - Section 125
- Check here to display the Salary Reduction Agreement
I understand and agree that: On this benefit enrollment form, I have enrolled for certain insurance coverage(s) and understand that an amount equal to the total amount of premium and/or contribution for coverage(s) elected less any non-elective employer contribution allocable thereto will be withheld from my salary, continuing for each pay period until this agreement is amended or terminated. The amount of my required contribution is set forth on a schedule that has been provided to me. In the event of a rate change, I authorize a corresponding change in the amount deducted from my salary without signing a new agreement. If the rate change is brought on by the third-party carrier (insurance company), the premium increase or decrease can be deducted pre-tax. However, if this change is brought on by my employer, the increase must be deducted after-tax. I understand that my actual take-home pay may be higher or lower depending on the coverage I select. In addition, pre-tax contributions reduce my compensation for Social Security tax purposes; therefore, my Social Security benefits could be decreased. I elect to receive the coverage under the Flexible Benefits Plan as elected. Any previous election under the Flexible Benefits Plan relating to the same benefits is hereby revoked. My employer’s deduction of premium/contribution amounts hereunder shall evidence acceptance of this agreement.

On or after the first day of the plan year, I cannot change or revoke this Salary Redirection Agreement with respect to pre-tax premiums before the next anniversary date of the plan unless a “change in status” occurs (as defined under the Internal Revenue Code), and the change is caused by and consistent with the “change in status.” I understand that I cannot revoke any pre-tax election based on a Right to examine provision as may be contained in any insurance plan or policy issue to me.

Execution of this Salary Redirection Agreement does not begin coverage under the component benefit plans or policies. New coverage will not become effective until the first day of the plan year. The terms and conditions and actual coverage effective date of the underlying coverage will be determined under the separate benefit plans or insurance policies. Prior to the anniversary date each year, I will be offered the opportunity to add, drop or change coverage for the following plan year. If I do not complete and return a new Salary Redirection Agreement form at that time, benefit plans or policies currently in effect will continue.

Paying for coverage on a pre-tax basis may cause insurance claim payments under health and medical coverage to be subject to federal and state taxes if claim payments (combining the total from all health and medical policies/plans) are in excess of medical expenses. Paying for disability income policies with pre-tax premiums will cause the benefits payable there under to be taxable. Such coverage may be funded on an after-tax basis to preserve the excludability of policy benefits.

I certify that the features and benefits under the Section 125 benefit plans have been explained to me completely. I understand that certain benefits may be elected on an after-tax basis. Except for a change in status, I understand that I cannot elect pre-tax benefits until the next open enrollment date, and that any after-tax coverage shall be outside the Section 125 plan.
Acknowledgement
I hereby declare that I am an active employee of GRBS and that I work at or from the employment location indicated. I understand that all my benefits will be taken on a pre-tax basis unless otherwise noted.
I declare to the best of my knowledge and based on the eligibility requirements, I am eligible to participate in the elected benefits.
I understand that if I waived coverage for any benefit and I want coverage at a later date I will be subject to a waiting period for these healthcare benefits or the next open enrollment
- Check here to accept
Electronic Signature
Date
MM slash DD slash YYYY
Form Complete
- Ready to Submit

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Name (Last, First, MI)	Date of Birth (MM/DD/YYYY)	Gender	Social Security Number	Relationship

Primary / Contingent	Name (Last, First, MI)	Date of Birth (MM/DD/YYYY)	Gender (M/F)	Social Security Number	Relationship	Annual Income	%

Benefits Election Form (2022)

Benefit Elections

Dependent and Beneficiary Information

Acknowledgement