Insurance Election for CLE – Community Living Experiences

First Name (applicant)

Last Name (applicant)

Medical Coverage *

Dental *

Vision *

Accident *

Voluntary Life *

Employee Only
Spouse
Child(ren)
Waive (opt out)

Note: New enrollments and enrollment changes require a completed application/change form. *Voluntary Life Coverage and cost information can be found in the Standard Booklet.

Signature *

Ohio Required Statement: Any person who submits an application or a claim containing a false or deceptive statement and does so with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, is guilty of INSURANCE FRAUD. AUTHORIZATION AND AGREEMENT: I understand this authorization revokes any previous salary reduction agreement for medical and dental insurance. I further understand that this authorization will remain in effect for all future Plan Years unless revoked or modified. I understand these payroll deductions cannot be adjusted during the Plan Year unless I experience a change in family status or other qualifying event as described in section 125 of the IRC and in the applicable Summary Plan Description. Any qualifying events must be submitted to Human Resources within the first 30 days of the event date. Employees participating in medical and/or dental plans who go on unpaid leave status will be required to make payments toward their insurance premiums.

Date *