Enrollment/Waiver Form Medical, Dental and Vision Insurance Effective April 1, 2023 Please enable JavaScript in your browser to complete this form.Name *FirstLastMedical Coverage *I am WAIVING medical coverage through the ICHRA (Individual Coverage Health Reimbursement Arrangement) effective March 1, 2023. NOTE: Horizon BCBS is terminating March 1, 2023 and being replaced by the ICHRA).I am ENROLLING in medical coverage through the ICHRA (Individual Coverage Health Reimbursement Arrangement) effective March 1, 2023 and have made my elections on the ICHRA benefits enrollment portal.Dental/Vision Coverage *I am CURRENTLY ENROLLED in dental and/or vision coverage and am NOT making any changes.I am NOT making any changes to my dental and vision coverage and am WAIVING coverage.I am MAKING CHANGES to my dental and vision benefits.Dental (Horizon Dental PPO) Weekly Payroll Deduction - Indicate your level of coverage *Levels of coverageEmployee Only - $5.76Employee/Spouse - $13.42Employee/Child(ren) - $11.81Family - $21.09WAIVE DentalVision (Horizon Vision PPO) Weekly Payroll Deduction - Indicate your level of coverage *Levels of coverageEmployee Only - $1.18Employee/Spouse - $2.37Employee/Child(ren) - $2.49Family - $3.47WAIVE VisionThe total amount being deducted weekly from my paycheck is: *Add together the Dental & Vision Weekly Payroll DeductionsWould you like to add a Health Savings Account (HSA)? HSA is only available for those enrolled in a qualified High Deductible Health Plan. HSA elections can be changed at any time. *YesNoHow much per paycheck would you like to contribute to the Health Savings Account (HSA)?I understand that my elections will continue until the next open enrollment in 2024 unless I experience a qualifying life event? *I understand. that I have an amount of flexible pay per period (combined HSA/Dental/Vision) for the purchase of qualified benefits as part of a flexible benefits plan ("plan") under Section 125 of the Internal Revenue Code. I hereby authorize and direct my employer to reduce my salary in the amount necessary to pay for the coverages that I have elected. Such reductions, considered elective contributions under the plan, shall commence with my next paycheck. I ruther authorize future adjustment in the amount of the salary reduction in the event that the cost of coverage in any program selected under the heading "Premium Conversion" is changed during the plan year. I also understand that the purpose of thise program is to allow employees to select their qualified benefits within the guidelines of the Internal Revenue Code. *Submit Form
