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09.14 – WHR 2012 Employee Benefit Enrollment Packet 2/15/12
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On Trac, Inc. New Employee Benefits Enrollment Packet
IMPORTANT INFORMATION- Please Read Carefully: The benefit enrollment documents and forms included in this “packet” are offered specifically by Windsor HR Services to eligible employees of On Trac, Incorporated. On Trac, Inc. may offer their own company-sponsored medical, dental, vision, or other benefits, and you may also be eligible to enroll in these separate programs – please contact either your Windsor HR Services Representative or your supervisor/manager for more information on these other benefits, and the necessary forms. In most cases, benefit eligibility begins with the conclusion of an employee’s 90-day probation period. You have thirty-one (31) days from your date of eligibility to complete and return the following benefits election section. If you choose to DECLINE any of the benefits offered, you still must indicate your decision by waiver on both the Flex Benefits Enrollment Form A and Flex Benefits Enrollment Form B-FSA, and return them to your company Windsor HR Services Representative. If you decline/waive enrollment in any benefit option and then decide later that you want to enroll, you must wait until the next open enrollment period to sign up.
Schedule of Annual Open Enrollment Periods
May: * Dental * Vision
July: * UNUM Life & AD&D Re-enrollment
(Only initial enrollment is Guaranteed Issue)
Nov/Dec: * Christmas Club * Section 125 FSA Plans * LegalShield and Identity Theft Shield
(If you are eligible for a group health insurance plan, please contact your supervisor/manager for information on those particular open enrollment dates).
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Windsor is proud to announce that effective June 1, 2011 our Dental Plans will change to reflect the requests of you, the employees, from our annual survey. The Diamond and Ruby Plans will no longer be available, but will be replaced with the Platinum, Gold and Silver Level Plans. The new plans feature the following:
• Allows you to use the dentists of your choice and obtain the service you and your dentist agree upon. • Has no waiting periods before certain procedures are covered. • Has no excluded procedures except cosmetic procedures (Bleaching, etc). • Has no requirement for pre-‐approval of the procedure. • Has no maximum fee schedule for each procedure. The dentist’s normal fees are allowable expenses. • Allows orthodontic care to be covered the same as any other dental procedure. (Refer to Orthodontic
Treatment Plan Form). There is no lifetime cap or age requirement on Orthodontics.
How the Plans work: • Every year beginning June 1st, you and your covered dependents will have either $2,000, $1,500 or
$1,000 in funds to use for dental and/or orthodontic care depending upon plan design. The plans reimbursements to you are as follows:
Platinum Plan • Will reimburse 100% of the first $200 of eligible expenses and then the plan will pay 50% of the next
$3600 of dental care for a total annual plan year reimbursement of $2,000. This plan offers orthodontic coverage.
Gold Plan • Will reimburse 100% of the first $150 of eligible expenses and then the plan will pay 50% of the next
$2,700 of dental care for a total annual plan year reimbursement of $1,500. This plan offers orthodontic coverage.
Sliver Plan • Will reimburse 100% of the first $100 of eligible expenses, then there is a $50 dollar deductible. The
plan will then pay 50% of the next $1,800 of dental care or a total annual maximum reimbursement of $1,000. This plan does not include orthodontic coverage.
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2011 Dental Plan Premium Rates (Monthly):
Platinum Annual Coverage $2,000-‐ with Orthodontic Employee $35.81 per month
Employee & Child(ren) $69.80 per month
Employee & Spouse $67.14 per month
Family $102.60 per month
Gold Plan: Annual Coverage $1,500-‐ with Orthodontic Employee $30.87 per month
Employee & Child(ren) $59.17 per month
Employee & Spouse $57.25 per month
Family $94.75 per month
Silver Plan: Annual Coverage $1,000-‐ without Orthodontic Employee $21.85 per month
Employee & Child(ren) $40.17 per month
Employee & Spouse $40.17 per month
Family $62.14 per month
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Please select your Premium Plan: Platinum Plan Gold Plan Silver Plan Please select your Coverage: Employee Employee & Spouse Employee & Child Family Name of Employee: __________________________________________________________________ Company Name: _____________________________________________________________________ Social Security No. ________-______-___________ Date of Birth: ______-______-__________ Address: ____________________________________________________________________________ ______________________________________ _____________ _____________________ City State Zip
NOTE: You MUST complete this next section if you are electing dependent coverage!
Record Dependent Information Here (for additional dependents use the back of this form) Spouse Name: ___________________________________________________________________________ Social Security No. ________-______-___________ Date of Birth: ______-______-__________ Children's Name* Date of Birth Relationship Social Security # __________________ _____-_____-_______ ____________________ _____-_____-______ __________________ _____-_____-_______ ____________________ _____-_____-______ __________________ _____-_____-_______ ____________________ _____-_____-______ __________________ _____-_____-_______ ____________________ _____-_____-______
*Dependent children between the ages of 19 & 26 must be unmarried
I apply for the coverage that I have elected/selected above. I am fully aware that:
1. Any premium required will be deducted from my paycheck on a pre-tax basis. 2. I am signing up for coverage until the next enrollment period and no changes can be made except for change in family status.
This information was explained to me prior to enrollment. By my signature below, I authorize any required payroll deduction and represent that all information shown on this form is correct. Employee Signature: _________________________________________ Date: _____________________ Employee e-mail address: ________________________________________________________________
INFORMATION BELOW MUST BE COMPLETED BY WINDSOR FOR COVERAGE TO BE EFFECTIVE:
Date of Hire: ______-______-_________ Effective Date of Coverage: ______-______-__________ Employer Signature: __________________________________ Late Applicant? Yes No
Windsor’s Royal Crown Dental Plan Enrollment Form
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Windsor’s Royal Crown Vision Plan from VSP
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RATES VALID UNTIL MAY 31, 2013
Please select a Monthly Coverage Plan: Employee ($11.96) Employee + one ($18.74) Employee + Children ($18.85) Family ($30.40) Name of Employee: __________________________________________________________________ Company Name: _____________________________________________________________________ Social Security No. ________-______-___________ Date of Birth: ______-______-__________ Address: ____________________________________________________________________________ ______________________________________ _____________ _____________________ City State Zip
NOTE: You MUST complete this next section if you are electing dependent coverage!
Record Dependent Information Here (for additional dependents use the back of this form) Spouse Name: ___________________________________________________________________________ Social Security No. ________-______-___________ Date of Birth: ______-______-__________ Children's Name* Date of Birth Relationship Social Security # __________________ _____-_____-_______ ____________________ _____-_____-______ __________________ _____-_____-_______ ____________________ _____-_____-______ __________________ _____-_____-_______ ____________________ _____-_____-______ __________________ _____-_____-_______ ____________________ _____-_____-______
*Dependent children between the ages of 19 & 26 must be unmarried
I apply for the coverage that I have elected/selected above. I am fully aware that:
1. Any premium required will be deducted from my paycheck on a pre-tax basis. 2. I am signing up for coverage until next enrollment period and no changes can be made except family status.
This information was explained to me prior to enrollment. By my signature below, I authorize any required payroll deduction and represent that all information shown on this form is correct. Employee Signature: ___________________________________ Date: _____________________ Employee e-mail address: ______________________________________________________________
INFORMATION BELOW MUST BE COMPLETED BY WINDSOR FOR COVERAGE TO BE EFFECTIVE:
Date of Hire: ______-______-_________ Effective Date of Coverage: ______-______-__________
Windsor’s Royal Crown VSP/Vision Plan Enrollment Form
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Windsor Christmas Savings Club
Do you get more than a little stressed about cash during and after the holiday season? Who wants to worry about December’s credit card bills over New Year’s? Why not avoid all of that stress and plan
ahead with Windsor’s Christmas Savings Club?
Earn 3% APY on your savings! Make sure you can pay your holiday bills this year. Plan ahead with Windsor HR Services and have all of your Holiday funds set aside by Thanksgiving. In fact, you’ll receive a better interest rate than a regular bank account! Why not collect interest on your money before the holidays instead of paying
interest after the presents are unwrapped? Enrollment is open for both full-time and part-time employees. As a Windsor Christmas Savings Club member, you’ll earn 3% APY on your Club Fund
money you choose to set aside from each paycheck during the year.
How Does it Work! Simply select an amount you would like deducted from your regular paycheck and your money will
be placed into a special Savings Club account that will earn you 3% APY. Deductions normally begin with your first paycheck in January. Then on the last Friday in November your Christmas
Savings Club check will arrive (with earned interest) and the shopping fun can begin. It’s that simple!
But you must remember…. The Windsor Christmas Savings Club Enrollment is only available
November & December of each year during the winter Windsor Open Enrollment period (effective date January 1), or for new hires upon their employment eligibility date through
September 31. Plan NOW to enroll!
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EMPLOYEE PAYROLL DEDUCTION ACKNOWLEDGMENT
WINDSOR CHRISTMAS CLUB SAVINGS FUND
I, _____________________________, hereby acknowledge On Trac, Inc./Windsor HR Services, Inc. and their subsidiaries, agents or assigns, (hereinafter On Trac, Inc./Windsor HR Services, Inc.) to make the deductions approved below, on my behalf, into the Windsor Christmas Club Savings Fund.
Periodic Deductions: Deduction Amount per pay period $ or %___________________
I understand that should my employment with On Trac, Inc./Windsor HR Services, Inc. cease at any time I will be entitled to all monies that I have contributed to the Christmas Club Savings Fund Account upon separation from the company.
______________________________________ Signed ______________________________________ Printed ______________________________________ Dated ____ I Decline to Enroll (Signature and Date Still Required)
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Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, ME 04122
Group/Voluntary Life Insurance Enrollment Form
FOR EMPLOYEE TO COMPLETE: WINDSOR HR SERVICES #:126417 EMPLOYEE NAME (last name, first, middle initial)
EMPLOYER/LOCATION NAME
EMPLOYEE ADDRESS (street, city, state, zip code)
SOCIAL SECURITY NUMBER DATE OF BIRTH
SEX SEX DATE DATE OF EMPLOYMENT
HOURS WORKED PER WEEK
30+ OCCUPATION
ANNUAL EARNINGS
SPOUSE’S DATE OF BIRTH
PROVIDED BY WINDSOR HR SERVICES, INC:
GROUP LIFE/AD&D: EMPLOYEE ONLY o $25,000 FLAT ……………………………………………………………………………………………………………………………………
PLEASE INDICATE YOUR VOLUNTARY LIFE COVERAGE ELECTION BELOW: VOLUNTARY LIFE: EMPLOYEE ONLY o $10,000 o $20,000 o $100,000 o $150,000 o OTHER ___________
DECLINE ____ NOTE: If you have chosen coverage over the Guarantee Issue amount of $150,000, you will also need to complete an Evidence of Insurability form. The amount of coverage over your Guarantee Issue amount will be subject to medical underwriting approval. If you DO NOT APPLY FOR coverage for you during the 31-DAY initial enrollment period, you will need to complete an Evidence of Insurability form for all amounts of coverage. This applies to Life coverage only.
Beneficiary Information Designate your beneficiary(ies) below. NAME OF BENEFICIARY (last name, first, middle initial) RELATION TO YOU BENEFIT %
IF THE BENEFICIARY(IES) NAMED ABOVE ARE NOT LIVING, THEN PAY:
REQUEST FOR SIGNATURE Please read the back of this form carefully before signing below. CERTIFICATION: I certify that all statements are true to the best of my knowledge and belief and I understand that a copy of this form will be made available at my request. I have read and understand the INFORMATION ABOUT DELAYED EFFECTIVE DATES and EXCLUSIONS on the reverse side of this enrollment form. I authorize my employer to make the necessary deductions from my salary or wages to pay the premium when my insurance becomes effective. I understand that my payroll deduction amount will change if my coverage or costs change. ___________________________________ __ __/__ __/__ __ __ ________________ ___________________ Employee Signature Date Work Phone Home Phone
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LIMITATIONS AND EXCLUSIONS
DELAYED EFFECTIVE DATE Employee: Insurance will be delayed for employees not in active employment until the first of the month, coincident with or next, following the date they return to work. Regularly scheduled vacation time is considered active employment.
EXCLUSION FOR SUICIDE Where the cause of death is suicide:
1. No benefits will be payable for a loss occurring within 24 months after the individual’s initial effective date of insurance; and 2. No increased or additional insurance will be payable for a loss occurring within 24 months after the day such increased or additional insurance is effective.
AD&D BENEFIT EXCLUSIONS
AD&D Benefits would not be paid for losses caused by, contributed to by, or resulting from:
• Disease of the body or diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders;
• Suicide, self-destruction while sane, or self-inflicted injury;
• War, declared or undeclared, or any act of war;
• Active participation in a riot; • Attempt to commit or
commission of a crime under state or federal law;
• The voluntary use of any prescription or non-prescription drug, poison, fume or any other chemical substance unless used according to the prescription or direction of the individual’s doctor. This exclusion does not apply to the individual if the chemical substance is ethanol; or
• Operating any motorized vehicle while intoxicated. (“Intoxicated” means that the individual’s blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state where the accident occurred.)
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UNUM CORPORATION LIFESTYLE LIFE
Windsor HR Services, Inc. Monthly Payroll Deduction
EMPLOYEE PREMIUM
$150,000 IS THE MAXIMUM THAT MAY BE ISSUED WITHOUT ANSWERING HEALTH QUESTIONS
*Age = Current Year – Birth Year
Age Band $10,000 $20,000 $30,000 $40,000 $50,000 $70,000 $100,000 $130,000 $150,000 0-24 $0.69 $1.38 $2.07 $2.76 $3.45 $4.83 $6.90 $8.97 $10.35 25-29 $0.79 $1.58 $2.37 $3.16 $3.95 $5.53 $7.90 $10.27 $11.85 30-34 $0.98 $1.96 $2.94 $3.92 $4.90 $6.86 $9.80 $12.74 $14.70 35-39 $1.39 $2.78 $4.17 $5.56 $6.95 $9.73 $13.90 $18.07 $20.85 40-44 $1.99 $3.98 $5.97 $7.96 $9.95 $13.93 $19.90 $25.87 $29.85 45-49 $3.17 $6.34 $9.51 $12.68 $15.85 $22.19 $31.70 $41.21 $47.55 50-54 $5.04 $10.08 $15.12 $20.16 $25.20 $35.28 $50.40 $65.52 $75.60 55-59 $7.75 $15.50 $23.25 $31.00 $38.75 $54.25 $77.50 $100.75 $116.25 60-64 $12.10 $24.20 $36.30 $48.40 $60.50 $84.70 $121.00 $157.30 $181.50 65-69 $21.00 $42.00 $63.00 $84.00 $105.00 $147.00 $210.00 $273.00 $315.00 70-74 $37.48 $74.96 $112.44 $149.92 $187.40 $262.36 $374.80 $487.24 $562.20 75+ $73.44 $146.88 $220.32 $293.76 $367.20 $514.08 $734.40 $954.72 $1,101.60
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Any time of year, Windsor’s Savings Connection
Program can help save you money and make those dreams come true.
As a member of the Windsor family you now get big savings at over 6000
merchants. Save 30% or more on movie tickets or a night out at that special restaurant. Take that long awaited vacation or if shopping is your
thing let your fingers do the walking at thousands of merchants.
To start saving now, just visit www.windsorhr.com and click on the Savings Connection link. Use Code: 10991 to save.
Need help? Just call 1-888-502-4961. Register your e-mail address with
Windsor and receive valuable coupons for even greater savings.
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Announcing Two New Voluntary Benefits for all Qualified Employees!
1. FAMILY LEGAL PLAN: For 36 years, we have put families like yours under the protection and counsel of thousands of law firms
in all 50 states. Today, over 1.5 million families have become members! § Have you wanted to update your Will? A Living Will is included. § Need to ask a question to an attorney? Telephone consultations are included. § Home purchase or refinance soon? Document review is included. § Traffic violations? Representation for moving violations is included. § Civil suit against you? Pre-trial and trial hours are included. § Challenge as a consumer? A letter written by an attorney is included. § Detained by a law enforcement officer at any time, day or night? Immediate consultation available. § Problem with a warranty, contractor, car dealership, mortgage, credit, etc.? We are there. § Before you sign a document, sit on hold or make a big decision, let us help!
2. IDENTITY THEFT SHIELD Identity theft is REAL! Over 252.2 million people have had their SS# and their information compromised by databases getting hacked or stolen since 2005- just look up TJ Maxx, Veterans Administration, etc. What if they got a job in your name? Committed Crimes in your name! HIV test? Passport? The average victim spends 600 hours & $1,500 clearing their good name. Do you know what to do? Do you have the time and patience to do that? What is the solution? IDENTITY THEFT SHIELD Covers you and your spouse or qualified significant other or domestic partner
§ Credit Report Analysis - You and your spouse receive a current credit report with a score analysis. § Continuous Monitoring of Credit Activities through Experian (24/7) Receive notification if one of
the following occurs: 1. An application for credit in your name; 2. An account is opened in your name; 3. Your address has been changed; 4. A derogatory statement shows up, or 5. A lien is on your property.
§ Full Identity Theft Restoration - Let us do the work for you! Experts at KROLL will issue the fraud alerts on your behalf and handle the credit card companies, financial institutions, all three credit repositories, Social Security Administration, Federal Trade Commission, Department of Motor Vehicles, law enforcement personnel and US Postal Service. Criminal activity searches will also be completed.
What is the cost?
$5.98 per week for BOTH (Family Legal Plan & Identity Theft Shield) $3.68 per week for Family Legal Plan only $2.99 per week for Identity Theft Shield only
Questions? Call Joe Holden (866-898-4140) at Windsor HR Services Inc. for information on enrollment.
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Employee Name: _________________________________________ SS#: _______-______-__________ Client/Worksite Name: On Trac, Incorporated The options provided under this plan must be made available to all Windsor HR Services Full Time employees. Please check all plans that you want to participate in on a pre-tax basis. Your elections will remain in effect throughout the benefit year. After making your selections, please sign and date the form. If you do not wish to participate in any of the plan options, please check the Waiver of Benefits section and sign below.
INSURANCE PREMIUM CONVERSION
I hereby elect to have Windsor HR Services deduct my contributions/premiums to the following group and/or supplemental benefits plans on a pretax basis (check below all that apply). I also acknowledge that enrollment in any of the employee benefits plans below, if available, requires that I complete a separate insurance company enrollment application form not included in this packet, and in some cases, be approved for coverage by the insurance company.
____ Group Health/Life ____ Supplemental Life (Max. $50,000 pretax)
____ Group Dental Insurance ____ Accident Insurance
____ Group Vision Insurance ____ Cancer Insurance
____ Short Term Disability ____ Other:______________________________________
WAIVER OF PRE-TAXED BENEFITS UNDER THE FLEXIBLE PLAN
I herby elect to waive all pre-tax benefits under the Flexible Benefits Plan, but understand that I may elect certain benefits on an after-tax basis. Except for a Qualifying Event/ Change in Status, I understand that I cannot elect pre-tax benefits until the next anniversary date.
This election to participate in (or waive participation in) the Windsor HR Services Flex Benefits Plan will continue until amended or revoked. I cannot change or revoke this Election before next open enrollment, unless I experience a Qualifying Event/ Change in Status (e.g., marriage, divorce, death of a spouse, birth or adoption of a child, or termination or commencement of employment of a spouse).
Employee’s Signature ___________________________________ Date ______/______/_________
Windsor HR Flex Benefits Enrollment: Form A
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Employee Name: ___________________________ SS#: _____-_____-_____ Client/Worksite Name: On Trac, Incorporated The options provided under this plan must be made available to all Windsor HR Services Full Time employees. Please check all plans that you want to participate in on a pre-tax basis. Your elections will remain in effect throughout the benefit year. After making your selections, please sign and date the form. If you do not wish to participate in any of the plan options, please check the Waiver of Benefits section and sign below.
FLEXIBLE SPENDING ACCOUNT [FSA] OPTIONS
I hereby authorize Windsor HR Services to reduce my compensation on pre-tax basis for the following expenses (check all that apply). I understand that I cannot change or revoke this salary redirection agreement before the next anniversary date of the plan unless a qualified change in family status occurs. The money that I set aside must be used for expenses incurred during the plan year (January 1 to December 31) in which I make the election. I have until March 31 to submit claims for the previous year. If I end my employment, I understand I have 30 days from date of termination to submit expenses. Any balance that I have in the account after March 31, or 30 days after my employment ends, will be forfeited/ lost.
____ Child/Dependent Day Care Expenses Total to be deducted per year $______________
(Maximum Authorized $5,000)
____ Un-Reimbursed Medical Expenses Total to be deducted per year $______________ (Maximum Authorized $3,000)
I agree that I will be reimbursed only for qualifying medical expenses and/or dependent care expenses. Upon demand, I also agree to reimburse Windsor HR Services for any liability it may incur for failure to withhold any payroll related taxes from any reimbursement I receive of Non-qualifying expense, up to the amount of additional tax actually owed by me. PLEASE NOTE: beginning Jan. 1, 2011, ALL over the counter medications are non-qualified expenses UNLESS accompanied by a signed doctor’s prescription.
WAIVER OF PRE-TAXED BENEFITS UNDER THE FLEXIBLE PLAN
I elect to waive all pre-tax benefits under the Flexible Benefits Plan, but understand that I may elect certain benefits on an after-tax basis. Except for a Change in Family Status, I understand that I cannot elect pre-tax benefits until the next anniversary date.
This election to participate in (or waive participation in) the Windsor HR Services Flex Benefits Plan will continue until amended or revoked. I cannot change or revoke this Election before next January 1st, unless I experience a change in family status (e.g., marriage, divorce, death of a spouse, birth or adoption of a child, or termination or commencement of employment of a spouse). Employee’s Signature ___________________________________ Date ______/______/_________
Windsor HR Flex Benefits Enrollment: Form B - FSA
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In an effort to improve communications and service to the employees of our client companies, Windsor HR Services, Inc. has established The Voice of Windsor e-news program. We will begin sending this quarterly newsletter directly to you as well as other announcements such as new benefit programs, open enrollment
forms, etc. upon your electing to enroll in this program. Your personal identity is protected under federal law, and we pledge to you that your e-mail address will never be sold or given to outside vendors. To enroll in the e-news program please complete this form and return it to
your HR Service Representative. If you choose not to enroll, please complete the opt-out section.
If you have previously enrolled or opted out, you do not have to complete another form.
Sign Me Up….. Thank You!
Employee Name (Print): ___________________________________ Date: _________________
Client Company: On Trac, Incorporated
E-mail address: ______________________________________________
Confirm e-mail address: ________________________________________________
Employee Signature: __________________________________________________ No Thanks… I want to Opt Out. I understand the e-news program and elect to opt-out at this time. I further understand that I will not be able to enroll in the program until the next open enrollment.
Employee Name (Print): ___________________________________ Date: _________________
Client Company: On Trac, Incorporated
Employee Signature: __________________________________________________
E-Mail Election or Opt-Out Form
