Benefit Overview/Enrollment Packet

Employee Benefits
www.essensebenefits.info
Open enrollment for January 2016 effective date
Employee Benefits Plan
We recognize that our employees are our most valuable resource and your benefits plan is extremely important to Essense of
Australia. Therefore, it is our pleasure to offer our benefits-eligible employees a variety of solutions to help address your benefit
needs, as well as the needs of your families.
Our employees continue to be the driving force behind our past success and position us well for the future. Thank you for your
ongoing commitment as we strive to be the best employer in our industry. We are proud to include all of you as part of the
Essense of Australia family.
This summary of benefits is intended only to highlight your benefits and should not be relied upon to fully determine coverage. This plan may not cover all your health care expenses. Please
refer to the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage.
Bukaty Companies Service Team
Essense of Australia Benefits Team
Elizabeth Wilson
Human Resources Specialist
913-213-5971
[email protected]
Renee Elliott
Executive Vice President,
Human Resources
913-213-5960
[email protected]
Andrea George
Human Resources Generalist
913-213-5970
[email protected]
Bukaty Companies Service Team
Brad Bukaty
Benefits Consultant
[email protected]
913-647-3945
Brad is the primary contact for
your benefits program.
Bukaty Companies
11221 Roe Ave.
Leawood, KS 66211
Phone: 913.345.0440
Fax: 913.345.2608
www.bukaty.com
Kim Romi
Client Service Manager
[email protected]
913-647-3971
Kim is responsible for day-to-day
administrative and service issues
including claims, billing, ID cards
requests, enrollment issues.
Rights & Disclosures
This information is intended to be shared by employees
with their spouse and dependents.
Special Enrollment Rights
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan
coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if
the employer stops contributing toward your or your dependents other coverage). However, you must request enrollment within 3 0 days after your or
your dependents other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent
as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must
request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or to obtain more
information contact Bukaty Companies at 888.657.0440.
Woman’s Health and Cancer Rights Act (WHCRA) of 1998
Do you know that your plan, as required by the Women’s Health and Cancer Rights Act (WHCRA) of 1998, provides benefits for mastectomy-related
services including all stages of reconstruction and surgery to achieve symmetry between breasts, prostheses, and complications resulting from a
mastectomy, including lymphedema? Call Bukaty Companies at 888.657.0440 for more information.
COBRA Rights In the Event You Lose Your Health (Medical/Dental/Flex) Coverage…
A group health plan is required to offer COBRA continuation coverage to you, your spouse and your dependents enrolled in the Plan when a
qualifying event occurs that causes loss of group health coverage. Coverage may be available for 18 months up to a maximum of 36 months,
depending upon the qualifying event. The employer is required to notify the Plan if the qualifying event is:
- Termination (for any reason other than gross misconduct) or reduction in hours of employment of the covered employee - eligible for
up to 18 months of continuation coverage
- Death of the covered employee - eligible for up to 36 months of continuation coverage
- Covered employee becomes entitled to Medicare - eligible for up to 36 months of continuation coverage depending upon date of
Medicare entitlement
The covered employee or one of the qualified beneficiaries is responsible for notifying the Plan Administrator within 60 days of the occurrence if the
qualifying event is:
- Divorce or legal separation - eligible for up to 36 months of continuation coverage
- A child’s loss of dependent status under the Plan - eligible for up to 36 months of continuation coverage.
Disability Extension
If you or anyone in your family covered under the Plan is determined by the Social Security Administration (SSA) to be disabled and you notify the
Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months o f coverage for a total of
29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until
the end of the 18-month period of continuation coverage. To obtain the extended coverage, a copy of the SSA disability determination must be
received by the Plan Administrator within 60 days after the determination is issued and within the individual’s first 18 months of continuation
coverage. If SSA determines later the individual is no longer disabled, that individual must notify the Plan Administrator wi thin 30 days after the date
of the second determination.
Second Qualifying Event
If while on 18 months of continuation coverage, family members enrolled in the Plan experience another qualifying event, they may be entitled to an
additional 18 months of coverage, for a maximum of 36 months. The extension may be granted if the employee or former employee dies, becomes
entitled to Medicare or gets divorced or legally separated, or if the dependent child loses dependent status, but only if the events would have caused
the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. When responsibility for notification rests
with the covered employee or qualified beneficiary, notice of the qualifying event must be made with in 60 days of the occurrence to the company’s
Plan Administrator.
Other Coverage Options Besides COBRA
Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance
Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enroll ment period.”
Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.
Questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to company’s Plan Administrator. For more
information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and
Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s
Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District
EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.
Keep Us Informed of Status Changes
It is very important that you keep your Plan Administrator informed of address changes and other personal data changes for yo u and/or dependents
who are or may become qualified beneficiaries on any of the company’s group benefits. Changes should be reported to the Plan Administrator.
A detailed explanation of COBRA rights and procedures is available in the Plan’s Summary Plan Description.
Premium Assistance under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your st ate may have a premium
assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for
Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the
Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State M edicaid or CHIP office
to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might b e eligible for either
of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you
qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer
must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportun ity, and you must request
coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the
Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums.
You should contact your State for further information on eligibility.
KANSAS – Medicaid
MISSOURI – Medicaid
Website:
http://www.kdheks.gov/hcf/
Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 1-800-792-4884
Phone: 573-751-2005
Lifetime limit
The lifetime limit on the dollar value of benefits under your group health plan no longer applies. Individuals whose coverage ended by reason
of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals have 30 days from the date of thi s notice to request
enrollment. For more information contact Bukaty Companies at 888.657.0440.
Medical: UnitedHealthcare
You are eligible to participate in medical benefit plan on the first of the month following date of hire. Eligible dependents may also
participate; eligible dependents include your legal spouse and/or dependent child(ren) age 26 and under. Further detailed benefit
description found on www.essensebenefits.info.
The following tables will give you an overview of how each of the options work. For questions concerning your medical benefits, a
claim, to identify an In-network provider, or if you have questions concerning your prescription drug coverage please contact United
Healthcare at 800.627.0687 or visit www.myuhc.com.
Network
Non-Network
Deductible
Individual/family (per calendar yr.)
$250/$750
$500/$1.500
Out-of-pocket max. individual/family
(per calendar yr.)
$2,250+Ded/$4.250+Ded
$4,500+Ded/ $8,500+Ded
90% after deductible
$20 Primary Care ($0 for
Pediatrician, Children<19)/$40
Specialist copay
60% after deductible
10% after Deductible
40% after deductible
Co-insurance
Office visit and specialist
X-ray and laboratory services
Preventive care
40% after deductible
100% covered by UHC
Pharmacy prescription drug coverage Month Supply:
Level 1/ Level 2/ Level 3
$10/$30/$50
$10/$100/$300 (Specialty Injectible RX)
Urgent care facility
$75 copay
40% after deductible
Inpatient hospital care
10% after Deductible
40% after deductible
Outpatient diagnostic and therapeutic procedures
10% after Deductible
40% after deductible
Emergency services
$200 +10% (Deductible doesn’t apply)
Durable medical equipment ($2,500 per calendar yr. max.)
10% after Deductible
40% after deductible
Physical therapy, occupational therapy and speech therapy
(limited to 20 visits per calendar yr.)
$20 copay
40% after deductible
Lifetime maximum
Unlimited
Medical Plan
Employee Only
Employee & Spouse
Employee & Child(ren)
Family
Employee Pays Per Paycheck
Rates are effective December 2015
$56.34
$304.24
$270.43
$518.34
Dental: Delta Dental of KS
Maintaining good dental health by getting regular checkups may prevent you from having major expenses later. The dental plan covers
routine checkups – and just about any other type of dental work you might need. You are eligible for benefits on the first of the month
following date of hire. Eligible dependents may also participate. Eligible dependents include your legal spouse who does not have
coverage available through their employer and/or dependent child(ren) under the age of 24, not eligible as a subscriber under another
dental plan.
To identify participating premier dentists, you may call Delta Dental at 800.234.3375 or visit their website at www.deltadentalks.com.
In-Network
Diagnostic
Basic
Major
Calendar year deductible
Calendar year benefit maximum
100%
80%
50%
$25x3
$1,500
Per Paycheck Rates
Employee Only
Employee/Spouse
Employee/Child(ren)
Family
Employee Pays
$6.12
$21.12
$20.31
$41.06
Basic Life / AD&D: Assurant (Employer Paid)
Benefit
Employee
1.5 x annual earnings ($200,000 maximum benefit)
Voluntary Life: Assurant
(Employee Paid on top of above basic life amount)
New hires currently becoming eligible may elect the following:
Employee
Spouse
Children
Up to $100,000 w/no medical questions
Up to $25,000 w/ no medical questions
$10,000 w/no medical questions
If voluntary life was declined earlier this year, by the employee, you may elect $20,000 on EE, $10,000 on spouse, and $10,000 on child.
If voluntary life was elected earlier this year, you may elect an additional $10,000 on EE, and an additional $5,000 on spouse without
medical questions.
Short-Term Disability: Assurant
Weekly Benefit Amount
Maximum Weekly Benefit
Minimum Weekly Benefit
Elimination Period
Benefit Duration
Rehabilitation Incentives
(Employer Paid)
60% of covered earnings
$2,000
$25
Accident – 15 days; Sickness – 15 days
11 weeks
Included
Your VSP Vision Benefits Summary
ESSENCE OF AUSTRALIA and VSP provide you with an affordable eyecare plan.
VSP Coverage Effective Date: 01/01/2016
Benefit
VSP Provider Network: VSP Choice
Description
Copay
Frequency
Your Coverage with a VSP Provider
WellVision Exam
Focuses on your eyes and overall wellness
Prescription Glasses
$20
Every 12 months
$20
See frame and lenses
Frame
$130 allowance for a wide selection of frames
$150 allowance for featured frame brands
$70 Costco® frame allowance
20% savings on the amount over your allowance
Included in
Prescription
Glasses
Every 24 months
Lenses
Single vision, lined bifocal, and lined trifocal lenses
Polycarbonate lenses for dependent children
Included in
Prescription
Glasses
Every 12 months
Lens Enhancements
Standard progressive lenses
Anti-reflective coating
Scratch-resistant coating
Average savings of 20-25% on other lens enhancements
Contacts (instead of
glasses)
$130 allowance for contacts; copay does not apply
Contact lens exam (fitting and evaluation)
$0
$0
$0
Up to $60
Every 12 months
Every 12 months
Glasses and Sunglasses
Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.
20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12
months of your last WellVision Exam.
Extra Savings
Retinal Screening
No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision Correction
Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
Your Bi-weekly
Contribution
$5.00 Member only
$7.99 Member + spouse
$8.16 Member + child(ren)
$13.16 Member + family
Your Coverage with Out-of-Network Providers
Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.
Exam .............................................................................. up to $45
Frame ............................................................................ up to $70
Single Vision Lenses ........................................... up to $30
Lined Bifocal Lenses ........................................... up to $50
Lined Trifocal Lenses ......................................... up to $65
Progressive Lenses ............................................. up to $50
Contacts .................................................................... up to $105
Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this
information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.
Contact us. 800.877.7195 | vsp.com
1
Brands/Promotion subject to change.
©
2014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Exam are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear,
Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.
Essense of Australia Benefits Enrollment Form
Employee’s Name
Address
Street
City
SSN
State
Date of Birth
_____/_____/_____
Open Enrollment
Zip Code
Gender
Marital Status
Male
Single
Female
Married
Home Phone
(
)
Date of Hire
_____/_____/_____
New Hire
Effective Date:
_____/_____/_____
Dependent Information
Name
SSN
Name
SSN
Name
SSN
Name
SSN
Name
SSN
Date of Birth
_____/_____/_____
Gender
Male
Female
Relationship
Date of Birth
_____/_____/_____
Gender
Male
Female
Date of Birth
_____/_____/_____
Gender
Male
Female
Date of Birth
_____/_____/_____
Gender
Male
Female
Date of Birth
_____/_____/_____
Gender
Male
Female
Relationship
Relationship
Relationship
Relationship
Coverage Options
Benefit
Employee
Only
Employee +
Spouse
Employee + Child(ren)
Family
Waive
Medical: UHC
Dental: Delta Dental
Vision: VSP
Short Term Disability: Assurant

Life Insurance: Assurant

Employer Paid 60% of Salary
Employer Paid 1.5x Annual Salary
Supplemental EE, Spouse & Child
Life Ins.
See attached enrollment form
Employee Signature
I hereby authorize my employer to deduct the appropriate premium contributions from payroll based on my benefit election choices.
Employee Signature: __________________________________ Date: ____/____/_____
If you are completely waiving all medical coverage, please check applicable reason below, then sign and date.
I am covered by spouse.
I am covered by my own separate individual plan.
I am covered by another entity, such as V.A., Tri-Care etc.
I am not covered elsewhere.
Employee Signature: __________________________________ Date: ____/____/_____
Employee Premium Deduction Schedule
Life Bi-Weekly Premium
Life Benefit in 000's
Age
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
$20 0.48
0.48
0.72
0.96
0.96
1.44
2.64
4.56
8.64
12.48
21.36
31.68
64.08
$30 0.72
0.72
1.08
1.44
1.44
2.16
3.96
6.84
12.96
18.72
32.04
47.52
96.12
$40 0.96
0.96
1.44
1.92
1.92
2.88
5.28
9.12
17.28
24.96
42.72
63.36
128.16
$50 1.20
1.20
1.80
2.40
2.40
3.60
6.60
11.40
21.60
31.20
53.40
79.20
160.20
$60 1.44
1.44
2.16
2.88
2.88
4.32
7.92
13.68
25.92
37.44
64.08
95.04
192.24
$70 1.68
1.68
2.52
3.36
3.36
5.04
9.24
15.96
30.24
43.68
74.76
110.88
224.28
$80 1.92
1.92
2.88
3.84
3.84
5.76
10.56
18.24
34.56
49.92
85.44
126.72
256.32
$90 2.16
2.16
3.24
4.32
4.32
6.48
11.88
20.52
38.88
56.16
96.12
142.56
288.36
$100 2.40
2.40
3.60
4.80
4.80
7.20
13.20
22.80
43.20
62.40
106.80
158.40
320.40
$110 2.64
2.64
3.96
5.28
5.28
7.92
14.52
25.08
47.52
68.64
117.48
174.24
352.44
$120 2.88
2.88
4.32
5.76
5.76
8.64
15.84
27.36
51.84
74.88
128.16
190.08
384.48
$130 3.12
3.12
4.68
6.24
6.24
9.36
17.16
29.64
56.16
81.12
138.84
205.92
416.52
$140 3.36
3.36
5.04
6.72
6.72
10.08
18.48
31.92
60.48
87.36
149.52
221.76
448.56
$150 3.60
3.60
5.40
7.20
7.20
10.80
19.80
34.20
64.80
93.60
160.20
237.60
480.60
$160 3.84
3.84
5.76
7.68
7.68
11.52
21.12
36.48
69.12
99.84
170.88
253.44
512.64
$170 4.08
4.08
6.12
8.16
8.16
12.24
22.44
38.76
73.44
106.08
181.56
269.28
544.68
$180 4.32
4.32
6.48
8.64
8.64
12.96
23.76
41.04
77.76
112.32
192.24
285.12
576.72
$190 4.56
4.56
6.84
9.12
9.12
13.68
25.08
43.32
82.08
118.56
202.92
300.96
608.76
$200 4.80
4.80
7.20
9.60
9.60
14.40
26.40
45.60
86.40
124.80
213.60
316.80
640.80
$210 5.04
5.04
7.56
10.08
10.08
15.12
27.72
47.88
90.72
131.04
224.28
332.64
672.84
$220 5.28
5.28
7.92
10.56
10.56
15.84
29.04
50.16
95.04
137.28
234.96
348.48
704.88
$230 5.52
5.52
8.28
11.04
11.04
16.56
30.36
52.44
99.36
143.52
245.64
364.32
736.92
$240 5.76
5.76
8.64
11.52
11.52
17.28
31.68
54.72
103.68
149.76
256.32
380.16
768.96
$250 6.00
6.00
9.00
12.00
12.00
18.00
33.00
57.00
108.00
156.00
267.00
396.00
801.00
55-59
60-64
65-69
70-74
75+
Life and AD&D Bi-Weekly Premium
131621_143682_1_042660_00001_00054
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
$20 0.72
0.72
0.96
1.20
1.20
1.68
2.88
4.80
8.88
12.72
21.60
31.92
64.32
$30 1.08
1.08
1.44
1.80
1.80
2.52
4.32
7.20
13.32
19.08
32.40
47.88
96.48
$40 1.44
1.44
1.92
2.40
2.40
3.36
5.76
9.60
17.76
25.44
43.20
63.84
128.64
$50 1.80
1.80
2.40
3.00
3.00
4.20
7.20
12.00
22.20
31.80
54.00
79.80
160.80
$60 2.16
2.16
2.88
3.60
3.60
5.04
8.64
14.40
26.64
38.16
64.80
95.76
192.96
$70 2.52
2.52
3.36
4.20
4.20
5.88
10.08
16.80
31.08
44.52
75.60
111.72
225.12
$80 2.88
2.88
3.84
4.80
4.80
6.72
11.52
19.20
35.52
50.88
86.40
127.68
257.28
$90 3.24
3.24
4.32
5.40
5.40
7.56
12.96
21.60
39.96
57.24
97.20
143.64
289.44
$100 3.60
3.60
4.80
6.00
6.00
8.40
14.40
24.00
44.40
63.60
108.00
159.60
321.60
$110 3.96
3.96
5.28
6.60
6.60
9.24
15.84
26.40
48.84
69.96
118.80
175.56
353.76
$120 4.32
4.32
5.76
7.20
7.20
10.08
17.28
28.80
53.28
76.32
129.60
191.52
385.92
$130 4.68
4.68
6.24
7.80
7.80
10.92
18.72
31.20
57.72
82.68
140.40
207.48
418.08
$140 5.04
5.04
6.72
8.40
8.40
11.76
20.16
33.60
62.16
89.04
151.20
223.44
450.24
$150 5.40
5.40
7.20
9.00
9.00
12.60
21.60
36.00
66.60
95.40
162.00
239.40
482.40
$160 5.76
5.76
7.68
9.60
9.60
13.44
23.04
38.40
71.04
101.76
172.80
255.36
514.56
$170 6.12
6.12
8.16
10.20
10.20
14.28
24.48
40.80
75.48
108.12
183.60
271.32
546.72
$180 6.48
6.48
8.64
10.80
10.80
15.12
25.92
43.20
79.92
114.48
194.40
287.28
578.88
$190 6.84
6.84
9.12
11.40
11.40
15.96
27.36
45.60
84.36
120.84
205.20
303.24
611.04
$200 7.20
7.20
9.60
12.00
12.00
16.80
28.80
48.00
88.80
127.20
216.00
319.20
643.20
$210 7.56
7.56
10.08
12.60
12.60
17.64
30.24
50.40
93.24
133.56
226.80
335.16
675.36
$220 7.92
7.92
10.56
13.20
13.20
18.48
31.68
52.80
97.68
139.92
237.60
351.12
707.52
$230 8.28
8.28
11.04
13.80
13.80
19.32
33.12
55.20
102.12
146.28
248.40
367.08
739.68
$240 8.64
8.64
11.52
14.40
14.40
20.16
34.56
57.60
106.56
152.64
259.20
383.04
771.84
$250 9.00
9.00
12.00
15.00
15.00
21.00
36.00
60.00
111.00
159.00
270.00
399.00
804.00
For premiums for benefit amounts not illustrated in this chart, please contact your Plan Administrator.
Life Insurance
Life Benefit in 000's
Age
5
Can I buy coverage for my family?
If you cover yourself, you can also purchase Voluntary Life Insurance for your eligible family members. You can buy spouse
coverage in units of $5,000, up to the lesser of 50% of your own coverage amount or $250,000. You can buy coverage for your
children too - in an amount of $1,000, $5,000 or $10,000. The 50% limit also applies to child coverage.
You can also buy AD&D coverage for your dependents, if you buy AD&D coverage for yourself. The Dependent AD&D amount
will match the Dependent Life amount.
Your eligible dependents include your lawful spouse, if not disabled or hospital confined on the effective date, and
unmarried children (if not hospital confined) from live birth to age 19, or to age 25 if a full-time student. The hospital
confinement exception does not apply to a child born while dependent insurance is in effect.
AD&D All Ages
Spouse Life Bi-Weekly Premium Deduction Schedule
Life Benefit in 000's
Age
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
All Ages
75+
$5 0.12 0.18 0.24 0.24 0.36 0.48 0.90 1.62 3.00 4.62 7.44 11.16 22.20
0.06
$10 0.24 0.36 0.48 0.48 0.72 0.96 1.80 3.24 6.00 9.24 14.88 22.32 44.40
0.12
$15 0.36 0.54 0.72 0.72 1.08 1.44 2.70 4.86 9.00 13.86 22.32 33.48 66.60
0.18
$20 0.48 0.72 0.96 0.96 1.44 1.92 3.60 6.48 12.00 18.48 29.76 44.64 88.80
0.24
$25 0.60 0.90 1.20 1.20 1.80 2.40 4.50 8.10 15.00 23.10 37.20 55.80 111.00
0.30
$30 0.72 1.08 1.44 1.44 2.16 2.88 5.40 9.72 18.00 27.72 44.64 66.96 133.20
0.36
$35 0.84 1.26 1.68 1.68 2.52 3.36 6.30 11.34 21.00 32.34 52.08 78.12 155.40
0.42
$40 0.96 1.44 1.92 1.92 2.88 3.84 7.20 12.96 24.00 36.96 59.52 89.28 177.60
0.48
$45 1.08 1.62 2.16 2.16 3.24 4.32 8.10 14.58 27.00 41.58 66.96 100.44 199.80
0.54
$50 1.20 1.80 2.40 2.40 3.60 4.80 9.00 16.20 30.00 46.20 74.40 111.60 222.00
0.60
$60 1.44 2.16 2.88 2.88 4.32 5.76 10.80 19.44 36.00 55.44 89.28 133.92 266.40
0.72
$70 1.68 2.52 3.36 3.36 5.04 6.72 12.60 22.68 42.00 64.68 104.16 156.24 310.80
0.84
$80 1.92 2.88 3.84 3.84 5.76 7.68 14.40 25.92 48.00 73.92 119.04 178.56 355.20
0.96
$90 2.16 3.24 4.32 4.32 6.48 8.64 16.20 29.16 54.00 83.16 133.92 200.88 399.60
1.08
$100 2.40 3.60 4.80 4.80 7.20 9.60 18.00 32.40 60.00 92.40 148.80 223.20 444.00
1.20
$110 2.64 3.96 5.28 5.28 7.92 10.56 19.80 35.64 66.00 101.64 163.68 245.52 488.40
1.32
$120 2.88 4.32 5.76 5.76 8.64 11.52 21.60 38.88 72.00 110.88 178.56 267.84 532.80
1.44
For Life and Accidental Death and Dismemberment insurance for your spouse, choose
the benefit you want. Your spouse’s premiums are based on your age.
For premiums for benefit amounts not illustrated in this chart, please contact your Plan
Administrator.
Child Life Bi-Weekly Premium
Benefit
$1,000
$5,000
$10,000
Child Life
0.08
0.42
0.84
Child Life and AD&D
0.09
0.48
0.96
For Life insurance for your child(ren), choose the benefit you want
for the corresponding premium. One premium covers all of your
eligible dependent children.
Limitations, exclusions, restrictions and reductions
Please carefully review the Other Important Plan Provisions section for additional important plan limitations, exclusions,
restrictions and reductions that may apply.
6
Employee Application
Please print clearly in blue or black ink.
ISSUE
Check one — Employer Use
o New Employee
o Change
o COBRA
Employee Information — Failure to accurately complete the questions on this application may affect the existence or amount of
coverage. Please correct any errors in the information listed below.
B Employer
Employee name (last, first, initial)
C
B Employment location
Essense of Australia
B Account # or Bill Group Name B Cert. #
Group policy/participant #
B Employee SSN
B Employee birthdate
5470562
Sex
m M
f F
title or position
Employee hire date
# hours per week Earnings $____________________ Married Children
B Job
B
B
B o Hourly o Weekly o Monthly B o Yes B o Yes
o Yearly o Other____________ o No
B
Address
B
City
State
B
o No
Zip
ELECTIONS ARE NOT VALID WITHOUT A SIGNATURE AT THE END OF THIS APPLICATION.
Dependent Information — Required if Dependent coverage applies
Name (Last Name, First Name) B
Date of Birth
:
:
:
B Gender B :
:
:
Relationship
:
:
:
NOTE — Coverage not elected will be assumed refused even if not specifically refused
Employee Choice Life Benefits
You may select the benefit(s) below. If you enroll, you will pay all or a portion of the premium.
Accept Refuse Coverage
o
o
Employee Voluntary Life - Amount ___________
o
o
Employee Matching Voluntary AD&D
o
o
Spouse Voluntary Life - Amount ___________
o
o
Spouse Matching Voluntary AD&D
o
o
Child(ren) Voluntary Life - Amount ___________
o
o
Child Matching Voluntary AD&D
Union Security Insurance Company
Mail To: Assurant Employee Benefits P.O. Box 981624 El Paso, TX 799981624
Form 61 (03/2010)
Application 131621_143682_1_042660_00001_00054
Page 1 of 4
Beneficiaries - Applies to all coverages for which a beneficiary designation is required
Last Name
First
MI B Relationship B
B o Primary
o Secondary
Bo Primary
o Secondary
If beneficiary is not related to you, please provide Date of Birth, Social Security Number, and full address.
1) Give FULL names and relationships of each beneficiary.
2) Beneficiaries elected will apply to all coverages elected on this form for which a beneficiary designation is
required.
3) If primary/secondary election is not noted, the beneficiary will be considered primary.
4) Proceeds will be paid in equal shares to those primary beneficiaries who survive you. If no primary beneficiaries
survive you, the proceeds will be paid in equal shares to the surviving secondary beneficiaries.
5) If your designation does not fit in the above arrangement, or you want to specify a beneficiary by coverage, please
contact Union Security Insurance Company for the appropriate forms.
MY SIGNATURE ON THIS APPLICATION CERTIFIES THAT I:
1) Apply for the coverages designated for which I am eligible under my employer’s plan with Union Security Insurance
Company.
2) Understand if coverages have been refused, I am not entitled to benefits under those coverages and that if I want to
apply later, I must furnish at my own expense proof of good health satisfactory to Union Security Insurance Company.
3) Authorize any required deductions from my earnings.
4) Designate the beneficiary named on this application to receive any benefits payable in the event of my death.
5) Represent that all of the information on this application is complete, correct and true to the best of my knowledge and
belief.
6) Understand that I must be actively at work the number of hours specified in the policy/participation agreement to remain
insured.
7) Understand that coverages include limitations and exclusions that may affect my entitlement to benefits. When
necessary, I may be asked to execute a HIPAA authorization form, allowing Union Security Insurance Company to use and
disclose protected health information.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
Employee’s signature_______________________________________________________ Date ____________________
Form 61 (03/2010)
Application 131621_143682_1_042660_00001_00054
Page 2 of 4
Flexible Spending Account Enrollment
Employer: ESSENSE OF AUSTRALIA
Social Security No:
Employee Name:
Date of Birth:
Home Address:
City/State/Zip:
Work Phone:
Email:*
Pay Period:
Payroll Effective Date:
* All plan communication pertaining to your account activity is provided solely via email and at the www. NueSynergy.com website. It is
important to notify NueSynergy if you change your email address.
Option 1: Group Insurance Premiums and/or HSA Contributions
I elect to have my group insurance plan premiums and/or Health Savings Account contributions paid with pre-tax dollars. I understand that if my
required contributions for the elected benefits are increased or decreased while this agreement is in effect, my taxable income will be automatically
adjusted to reflect that increase or decrease. I understand the IRS regulations require that I remain enrolled in all benefits for the entire plan year,
unless I experience a qualifying event that permits a change.
I decline participation for the current plan year.
Option 2: FSA Health Care Account – Select one only; maximum annual contribution is $2,550.
Waiver
I decline to enroll in this
option for the current plan
year.
General Purpose FSA
I elect to enroll in the General Purpose FSA for medical, vision and/or dental expenses*
$________________
Pre-tax contribution per pay period
$________________
Pre-tax plan year contribution
*I acknowledge that I and my spouse will not contribute to a Health Savings Account (HSA) during the plan year. To do so would
prevent us from enrolling in the General Purpose FSA.
Option 3: Dependent Daycare Reimbursement Agreement - $5,000 plan year maximum; $2,500 for married filing separately
I elect to contribute $________ (pre-tax) per pay period, which is $_________ for funding of qualified dependent care expenses.
I decline to enroll in this option for the current plan year.
Beneficiary Designation: In the event of my death, my designated beneficiary may have certain obligations and responsibilities to file claims and seek reimbursement under the terms of
the plan. I therefore designate as my beneficiary under the plan:
Name:
Address:
Relationship:
Others Terms and Conditions: I understand that I cannot change or revoke this compensation redirection agreement at any time during the plan year unless I experience a qualifying
event (including marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of employment of a spouse or such other events as the plan
administrator determines will permit a change or revocation of an election). The plan administrator may reduce or cancel my compensation redirection or otherwise modify this
agreement in the event it is advisable to satisfy certain provisions of the Internal Revenue Code. The authorized redirection of my cash compensation under this agreement shall be in
addition to any redirection under other agreements or benefit plans Any remaining account balances following the end of my plan’s designated run-out period will be forfeited, or carried
over up to $500 to the following plan year if my employer elected the carryover provision. By participating in one of the plan options defined above, I acknowledge my Social Security
benefits may be slightly reduced.
Signature:
Administration Services, 10901 Granada Lane, Suite 100, Leawood, KS 66211
Phone: 913.653.8381, Toll-Free: 855.890.7239, Fax: 855.890.7238
Email: [email protected]
10-2014
Date:
Direct Deposit Authorization Form
Direct deposit of your FSA and/or HRA reimbursements is a convenient feature. By completing the authorization form
below, you are directing your employer and financial institution to deposit your reimbursements to the checking or savings
account you designate.
To sign up for direct deposit, simply complete the form as directed below and return it to NueSynergy, your FSA and/or
HRA administrator. Be sure to:
 Fill out the form completely.
 Mark the appropriate box to indicate whether your reimbursement will be deposited to your checking or
savings account.
 Attach a voided check to the form if you want reimbursements deposited in your checking account. Attach a
voided deposit slip if you want reimbursements deposited to your savings account. *
New enrollment
Banking Information:
Change of information
Checking (attach a voided check)
Savings (attach a deposit slip)
*Direct deposit cannot be processed without a voided check/deposit slip.
Employer:
Employee/Participant
Name:
Social Security
Number:
Date of Birth:
Address:
City/State/Zip:
Daytime
Phone:
Email:
Financial Institution/Depository:
Branch:
City:
State:
Account #:
Routing #: (9 digits)
By completing and signing this Authorization Form, I, the PARTICIPANT, am directing my EMPLOYER/ADMINISTRATOR and FINANCIAL
INSTITUTION/ DEPOSITORY to deposit my reimbursements to my designated checking or savings account. The FINANCIAL INSTITUTION/
DEPOSITORY indicated above is authorized to credit the same to such account. I also authorize my EMPLOYER/ADMINISTRATOR to draw drafts
on my account or to initiate debit entries to my account, solely for the purposes of adjusting an error resulting from a deposit or credit entry that has been
made under this Authorization in an amount that is not correct. The FINANCIAL INSTITUTION/DEPOSITORY shall not be liable for honoring any
draft, debit entry or withdrawal initiated by my EMPLOYER/ADMINISTRATOR.
Should my EMPLOYER/ADMINISTRATOR be unable to stop from posting an entry with respect to which I, the PARTICIPANT, have requested
cancellation or amendment or should the EMPLOYER/ADMINISTRATOR be unable to withdraw the entry from the ACH Origination System, I, the
PARTICIPANT, may initiate a reversal to correct the entry, as provided by the ACH Rules. Where I, the PARTICIPANT, initiate a reversal for an
individual entry, I, the PARTICIPANT, must notify the EMPLOYER/ADMINISTRATOR of the entry no later than the settlement date of the reversing
entry. Reversals do not guarantee that the funds will be returned and the EMPLOYER/ADMINISTRATOR shall not have liability if such reversal is not
effected. I, the PARTICIPANT, shall reimburse my EMPLOYER/ADMINISTRATOR for any expense, losses, or damages the
EMPLOYER/ADMINISTRATOR may incur in effecting or attempting to affect the reversal of an entry.
Signature:
Date:
Administration Services, 10901 Granada Lane, Suite 100, Leawood, KS 66211
Phone: 913.653.8381, Toll-Free: 855.890.7239, Fax: 855.890.7238
Email: [email protected]
9-2013