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MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL PLAN 3.1.2016-2.28.2017 Dental Abramova, Alena is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea: 1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura * Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017 1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor) 2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________ ________ Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________ Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________ Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________ Enrolled in parent’s Medical insurance- Carrier Name and ID# Inscritos en el seguro Médico de los padres - Nombre del portador y el # del TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057 TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
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MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalAbramova, Alena is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalAlvarado, Adriana M is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalAlvarez, Gregorio is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalAlvarez, Pedro A is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalAnsah-Owusu, Kwame is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalBarney, Romano J is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalBenvenuto, Donald is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalBoone, Pamela O is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Children and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalBriones, Roberto is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Children and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalBrosius, Lisa M is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalBudd, Kari A. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalByfield, Maurice is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalCarbajal, Luis is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalChrupalyk, Erik M is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalConstantine, Michael W is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalCrosse, Clayton is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalDemshick, Cynthia A. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Spouse and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalFenton, Richard G. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalFinnegan, Kathryn A is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalFish, Kristopher is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:Executive(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalGrdinich, John E is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:Executive(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalHein, Judy A. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalHeisen, Jessica is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalHernandez, Gorge A is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalHyman, Ambra is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalJames, Celeste A. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalJohnston, Thomas is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalKacala, Francesca E is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalLainez Delcid, Fredy is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalLucas, Kevin A. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalMcCausland, Sandra is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalNavarro, Carlos N. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalNewton, Stephen J is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:Executive(Allied Administrators For Delta Dental)Employee + Spouse and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalNieves, Teresa M is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalOakley, Steven M is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:Executive(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalPanczyszyn, Natalia is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalPaz, Eriber is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalPepper, Anne K is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:Executive(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalPerez-Barragan, Juan is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalRenzulli, Nicholas J. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalSegundo, Rene V is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalSegundo-Reyes, Joaquin is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalSmith, Richard L is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalTaylor, Paul M. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalThomson, Jacqueline J. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalUrban, Kristine A. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalVetter, Luz A. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Spouse and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalWeisel, Taylor J is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalWilcox, Alexis is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Family and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalWoods, Tyler A. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalWright, James Alexander is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:Executive(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalWulliger, Psachya is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee + Spouse and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
MEDICAL AND DENTAL COVERAGE FORM/ COVERTURA MEDICA Y DENTAL
PLAN 3.1.2016-2.28.2017
DentalYoung, Patricia Y. is currently enrolled in/ está inscrito en Delta Dental PPO Plus Premiere 4:FT Regular(Allied Administrators For Delta Dental)Employee and would like to/ y desea:
1. Continue with my coverage with no changes/ continuar con la cobertura sin cambios 2. Make changes / hacer cambios:_________________________________ 3. Discontinue my Dental Coverage*/ descontinuar la cobertura *
Medical I wish to enroll in the Medical Plan 2016-2017/ Yo deseo inscribirme en el Plan Médico 2016-2017
1. PPO Plus 10B HSA (please complete enrollment form)/ PPO Plus 10B HSA (complete la hoja de inscripción porfavor)
2. PPO Plus 6B (please complete enrollment form)/PPO Plus 6B (complete la hoja de inscripción porfavor) 3. I wish to waive the Medical Coverage. */ Yo no deseo participar en el Plan Médico
Reason for declining coverage: Covered by spouse’s group Medical coverage – Carrier Name and ID #__________________________________________________
Cubierto por la cobertura Médica de mi pareja - Nombre de la aseguradora y el # del ID:__________________________________
Enrolled in other Medical insurance carrier’s plans – Carrier Name and ID #________________________________________
Inscritos en otro plan de seguros Médico - Nombre del portador y el # del ID: ___________________________________________
Enrolled in parent’s Medical insurance- Carrier Name and ID# ________________________________________________________________
Inscritos en el seguro Médico de los padres - Nombre del portador y el # del ID:____________________________________________
Medicare_______________________________________________________ Medicare_______________________________________________________ Other (explain) ________________________________________________ Otro (explique)________________________________________________ Enrolled in other Dental carrier- Carrier Name and ID#_________________________________________________________________
Inscrito en otro plan Dental-Nombre del portador y el # de ID: _____________________________________________________________
*I acknowledge I have been given the right to apply for these coverages; however, I am electing not to enroll. By declining these group coverages I acknowledge that I and/ or my dependents may have to wait until the next open enrollment in February 2017.
* Yo reconozco que se me ha dado el derecho de inscribirme en las coberturas médica y dental; sin embargo, he elegido no participar. Rechazando estas coberturas, yo entiendo que yo y/ o mis dependientes tengamos que esperar a la próxima fecha de aniversario de los planes para inscribirnos en la cobertura.
Employee Signature/Firma del Empleado: ___________________________ Date/Fecha:__________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
Human Resources/ Recursos Humanos: ______________________________ Date/Fecha: __________
TThe Solid Wood Cabinet Company 6300 Bristol Pike • Levittown, PA 19057TEL: 267.288.1200 • FAX: 267.288.1206 • www.SolidWoodCabinets.com
