Benefit Acknowledgement Form

Partners that are hired to work 20-40 hours per week (.5-1.0 fte) are required to complete electronic enrollment. Partners have the option of enrolling in benefits or waiving coverage.

Online electronic enrollment includes the following benefits: Health, Dental, Vision, Supplemental Life, Dependent Life and Flexible Spending.

I understand that if I am eligible for the above benefits I need to complete the online electronic enrollment within 30 days of my hire date. Once the 30 days has elapsed, unless there is a qualifying event, I will need to wait until the next open enrollment in order to enroll. Partners eligible for health insurance who choose not to elect coverage are required to waive coverage. Partners that are hired to work 30-40 hours per week (0.75-1.0 fte) who do not enroll or waive coverage will automatically be enrolled in the MercyCare EPO HDHP plan.

Plan carefully when you elect your benefits choices (including election to waive coverage) as they will remain in effect for the remaining plan year. Federal laws govern that you only change your health, dental and flexible plan coverage during the plan year if there is an IRS qualifying event including: change in family status (gain or loss of dependent) or employment status (loss or gain of medical coverage). The change in coverage for which you apply should be consistent with the change in family or employment status. You must apply for the change of coverage within 30 days of the qualifying event or wait until the next open enrollment. Contact Human Resources at 800-236-6721 for assistance.

Checkbox *

Checkbox I understand that based on my date of hire, Health, Dental, STD, & Flexible Spending benefits are effective 1st of the month following 30 days from my date of hire (in cases where the 30th day is the 1st, benefits will be effective that day).
Checkbox *

Checkbox I understand that based on my date of hire, life benefits are effective 1st of the month following 90 days from my date of hire (in cases where the 90th day is the 1st, benefits will be effective that day).
Checkbox *

Checkbox I understand that I must complete new hire enrollment elections by the 30th day from my date of hire or risk being auto enrolled in the EPO HDHP plan (partners who are hired to work 30-40 hours per week, .75-1.0 fte risk auto enrollment) and STD 30 day waiting period plan (partners who are hired to work 20-40 hrs per week, .5-1.0 fte risk auto enrollment).
Name Name * First Last
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.