Master Benefit Application

PALERMO’S BENEFIT APPLICATION
Benefits Effective Date: Click here to enter text.
REASON FOR APPLICATION:

New Enrollment Qualifying Event:
If yes, please provide specific event and date:
TYPE OF COVERAGE FOR MEDICAL/HEALTH REIMBURSEMENT ACCOUNT:
Employee Only Employee / Child Employee / Spouse

Family Waive: If so, why:
TYPE OF COVERAGE FOR DENTAL:
Employee Only Family

Waive: If so, why:
TYPE OF COVERAGE FOR VISION:

Employee Only Limited Family Family
Waive: If so, why:
TYPE OF COVERAGE FOR VOLUNTARY LIFE INSURANCE:
With AD&D Employee Amount: Spouse Amount:

Dependent Child = $10,000 per child Waive
TYPE OF COVERAGE FOR 401(k) Retirement Plan: (See Enrollment Forms)
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Enroll Waive
Roth:% $ Pre-tax: % $
FLEXIBLE SPENDING ACCOUNT (See Enrollment Forms)

Enroll Waive
Medical: $ /year Dependent Care: $ /year
EMPLOYEE INFORMATION:
Last Name First Name Date of Birth Gender
Click here to Click here to Click here to enter Male Female

enter text. enter text. text.
Social Home Address: Street/City/State/Zip Home Telephone

Security
Click here to enter text. Click here to enter text.
Number
Click here to
enter text.
Single Full-time Date Occupation Hours/week

Divorced of Hire
Click here to enter Click here to enter text.
Married Click here to text.
Widowed enter text.
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DEPENDENT INFORMATION:
1. Last Name First Name Date of Birth Social Security Number
Click here to Click here to enter Click here to Click here to enter text.
enter text. text. enter text.
Relationship:
Spouse Son Daughter Other:
Full-time Is Address Same as Above: Yes No

Student
If No, please provide address: Click here to enter text.
Yes No
Click here to Click here to enter Click here to Click here to enter text.
enter text. text. enter text.
Relationship:

Student
Yes No
Click here to Click here to Click here to Click here to enter text.
enter text. enter text. enter text.
Relationship:

Student
Yes No
Click here to Click here to Click here to Click here to enter text.
enter text. enter text. enter text.
Relationship:
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Student
Yes No
PRIOR HEALTH COVERAGE

Yes No Name of Prior Date Policy in Date Policy Ended:
Carrier Effect:
Click here to enter text.
Click here to enter Click here to enter
text. text.
Type of Coverage with prior carrier Type of Benefit
Employee Only Medical Dental Vision

Employee/Child
Employee/Spouse Family
Reason for termination of prior coverage:
Divorce/Legal Separation Death of Spouse COBRA coverage

exhausted
Employment Terminated Group Plan terminated Employer contribution

ceased
Other: Click here to enter text.
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LIFE INSURANCE / 401K BENEFICIARY
Primary Beneficiary Last/First Relationship of Social Security
Name: Beneficiary Number
Click here to enter text. Click here to enter text. Click here to enter text.
Street Address/City/State/Zip: Percent
Click here to enter text. Click here to enter text.
Secondary Beneficiary Last/First Relationship of Social Security

Name: Beneficiary Number
Click here to enter text. Click here to enter text. Click here to enter text.
Street Address/City/State/Zip:Click here to enter text. PercentClick here to

enter text.
SIGNIFICANT TERMS, CONDITIONS AND AUTHORIZATIONS

Please read this section carefully before signing the application:
1. I may not assign any payment under my Anthem Blue Cross Blue Shield program.
2. I authorize deduction from my wages/pension, if necessary for the required premium
for the coverage for which I or any dependents have applied.
3. I am applying for the coverage selected on this application. If I select coverage, or
combination of coverage’s not available to me and / or a class for which I am not
eligible, I agree that my selection(s) is hereby automatically amended to be consistent
with the employer application.
4. I understand that, to the extent permitted by law, Anthem, Delta Dental, Vision Plan
of America, Diversified Benefit Services, Lincoln Financial Group, reserves the right to
accept or decline this application (and that Anthem Life Insurance Company may accept
only certain persons or conditions for coverage) and that no right whatsoever is created
by this application. I also understand that this coverage, if approved, may exclude
coverage for pre-existing conditions.
5. I am responsible to timely notify my employer of any change that would make me or
any dependent ineligible for coverage.
6. By signing this application, I agree and consent to the recording an / or monitoring of
any telephone conversation between Anthem, Delta Dental, Vision Plan of America,
Diversified Benefit Services, Lincoln Financial Group, and myself.
I acknowledge that I have read the Significant Terms, Conditions and Authorizations,
and I accept such provisions as a condition of coverage. I represent that the answers
given to all questions on this application are true and accurate to the best of my
knowledge and I understand they are being relied on by Anthem, Delta Dental, Vision
Plan of America, Diversified Benefit Services, Lincoln Financial Group, in accepting this
application. I understand that any misstatements or failure to report new medical
information prior to my effective date may result in a material change to coverage or
premium rates. Any material misrepresentation or significant omission found in this
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application may result in denial of benefits or rescission or cancellation of my
coverage(s). Commits a fraudulent insurance act, which is a crime.
I give this authorization for and on behalf of any eligible dependents and myself if
covered by the Plan. I am acting as their agent and representative.
EMPLOYEE SIGNATURE: DATE:
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PALERMO’S BENEFIT APPLICATION

Benefits Effective Date: Click here to enter text.

REASON FOR APPLICATION:

TYPE OF COVERAGE FOR MEDICAL/HEALTH REIMBURSEMENT ACCOUNT:

Employee Only Employee / Child Employee / Spouse

TYPE OF COVERAGE FOR DENTAL:

Employee Only Family

TYPE OF COVERAGE FOR VISION:

TYPE OF COVERAGE FOR VOLUNTARY LIFE INSURANCE:

With AD&D Employee Amount: Spouse Amount:

TYPE OF COVERAGE FOR 401(k) Retirement Plan: (See Enrollment Forms)

FLEXIBLE SPENDING ACCOUNT (See Enrollment Forms)

Click here to Click here to Click here to enter Male Female

Social Home Address: Street/City/State/Zip Home Telephone

Single Full-time Date Occupation Hours/week

Spouse Son Daughter Other:

Full-time Is Address Same as Above: Yes No

2. Last Name First Name Date of Birth Social Security Number

Spouse Son Daughter Other:

Full-time Is Address Same as Above: Yes No

3. Last Name First Name Date of Birth Social Security Number

Spouse Son Daughter Other:

Full-time Is Address Same as Above: Yes No

4. Last Name First Name Date of Birth Social Security Number

Spouse Son Daughter Other:

PRIOR HEALTH COVERAGE

Type of Coverage with prior carrier Type of Benefit

Employee Only Medical Dental Vision

Reason for termination of prior coverage:

Divorce/Legal Separation Death of Spouse COBRA coverage

Employment Terminated Group Plan terminated Employer contribution

Other: Click here to enter text.

Street Address/City/State/Zip: Percent

Click here to enter text. Click here to enter text.

Secondary Beneficiary Last/First Relationship of Social Security

Street Address/City/State/Zip:Click here to enter text. PercentClick here to

SIGNIFICANT TERMS, CONDITIONS AND AUTHORIZATIONS

EMPLOYEE SIGNATURE: DATE:

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