Benefit Enrollment Form | Dream Team Pizza

2022 BENEFIT ENROLLMENT FORM
(not phone compatible)

Employee Information

First Name

Middle Name

Last Name

Social Security Number

Birthday

Date of Hire

Marital Status

Address

City

State

Phone

Dependent Information

Last Name

First Name

Middle Initial

Social Security Number

Birthday

Last Name

First Name

Middle Initial

Social Security Number

Birthday

Last Name

First Name

Middle Initial

Social Security Number

Birthday

Last Name

First Name

Last Name

First Name

Middle Initial

Social Security Number

Birthday

Middle Initial

Social Security Number

Birthday

Last Name

First Name

Middle Initial

Social Security Number

Birthday

Last Name

First Name

Middle Initial

Social Security Number

Birthday

Medical (Insurance by HUMANA)

Employee's MONTHLY COST | SELECT ONLY ONE

PLANS

Bronze Plan
(single/family)
Deductible: ($4,000/$8,000)
Coinsurance: 50%
Office: (50% after Deductible Met)

Gold Plan
(single/family)
Deductible: ($0/$0)
Coinsurance: 0%
Office: ($40/$80)

I do not want MEDICAL Insurance

Employee

Employee + Spouse

Employee + Child(ren)

Employee + Family

$102.21

$204.43

$194.21

$327.09

$256.64

$513.28

$487.62

$821.25

Vision Insurance

Employee's MONTHLY COST - SELECT ONLY ONE

I do not want VISION Insurance

Dental Insurance

Employee's MONTHLY COST - SELECT ONLY ONE

I do not want DENTAL Insurance

Employee

Employee + Spouse

Employee + Child(ren)

Employee + Family

$7.05

Employee

$24.38

$14.97

$52.66

Employee + Spouse

$15.86

$61.22

Employee + Child(ren)

$25.55

$93.90

Employee + Family

Agreement and Signature

I understand by signing this form that I am making a binding election for my benefits for the period of January 1, 2021 through December 31, 2021. I also understand that I may not change my benefit election unless the changes are a result of a qualifying event (e.g. marriage, divorce, birth or adoption, death of a dependent, or change in my spouse's status that effects eligibility).

NOTE: If you experience a qualifying event, you MUST notify PeopleFirst (HR) within 30 days of your status change. The rates given are subject to change with notice.

I verify to the best of my knowledge the information provided on this enrollment form is true and correct to the best of my knowledge.

Employee Signature

Date

Supporting PDF Downloads

2022 Employee Benefit Notices

Dream Team 2022 Benefit Overview

THANK YOU FOR SBUMITTING YOUR EMPLOYEE BENEFIT ENROLLMENT FORM ONLINE. YOU WILL RECEIVE FURTHER INFORMATION ON ENROLLMENT FROM THE PEOPLEFIRST DEPARTMENT SOON.

This form no longer accepts submissions. The open enrollment period has ended. Please reach out to the PeopleFirst (HR) department for questions.

2022 BENEFIT ENROLLMENT FORM (not phone compatible)

Employee Information

Dependent Information

Medical (Insurance by HUMANA)

Employee's MONTHLY COST | SELECT ONLY ONE

PLANS

Bronze Plan (single/family) Deductible: ($4,000/$8,000) Coinsurance: 50% Office: (50% after Deductible Met)

Gold Plan (single/family) Deductible: ($0/$0) Coinsurance: 0% Office: ($40/$80)

Employee

Employee + Spouse

Employee + Child(ren)

Employee + Family

Vision Insurance

Employee's MONTHLY COST - SELECT ONLY ONE

Dental Insurance

Employee's MONTHLY COST - SELECT ONLY ONE

Employee

Employee + Spouse

Employee + Child(ren)

Employee + Family

Employee

Employee + Spouse

Employee + Child(ren)

Employee + Family

Agreement and Signature

​

NOTE: If you experience a qualifying event, you MUST notify PeopleFirst (HR) within 30 days of your status change. The rates given are subject to change with notice.

I verify to the best of my knowledge the information provided on this enrollment form is true and correct to the best of my knowledge.

Supporting PDF Downloads

2022 BENEFIT ENROLLMENT FORM
(not phone compatible)

Bronze Plan
(single/family)
Deductible: ($4,000/$8,000)
Coinsurance: 50%
Office: (50% after Deductible Met)

Gold Plan
(single/family)
Deductible: ($0/$0)
Coinsurance: 0%
Office: ($40/$80)