Health Plan Employee Enrollment Form

  • The employee enrolling in the plan must be actively working and paid for working 20 hours or more per week.
  • Except for address or beneficiary changes, Alliance Benefits must be notified within 30 days of a qualifying event (new hire, marriage, newborn, etc.) to enroll or make changes to your plan. If Alliance Benefits is not notified within the 30-day window, you must wait until the next open enrollment period to enroll or make changes to your plan.
  • The new enrollment effective date is the first day of the month following the qualifying event date. If the event date falls on the first day of the month, coverage will begin on this day.

Reason for Enrolling

Please select your reason for enrolling: *
 
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General Information

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Benefit Election

Medical Benefits: *
Coverage Type: *

Dependent Information

  List spouse and/or children to be covered (eligible children are those under the age of 26)
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Are you or any of your dependents (including spouse) covered under another health plan or Medicare?

Beneficiary Designee for Life Insurance

Basic Life Insurance is for $30,000 and is automatically included in your health plan package. Voluntary Life Insurance is elected. Please designate beneficiaries below:

Voluntary Life Insurance

Additional life insurance coverage may be purchased for employee, spouse and children (through age 25) if the employee is enrolled in the health plan package. Please refer to the Alliance Health Plan Summary Guide located on the Alliance Benefits website (www.alliancebenefits.org) for requirements and rates.
Employee Voluntary Life Insurance: * 🛈
Spouse Voluntary Life Insurance: * 🛈
Child Voluntary Life Insurance: * 🛈

HSA Account Set-Up

Once enrolled, you will automatically be set up with a health savings account (HSA) to receive employer contributions included in the monthly premium. More details will be sent regarding your account set up at the time your enrollment has been processed. If you wish to contribute additional funds to your HSA, please work with your employer to include this amount on the Employer Certification Form.
 
The following are ineligible to participate in an HSA::
  • Those enrolled in Medicare, Tricare, or a Veteran's plan
  • Those enrolled in additional coverage that is not a High Deductible Health Plan (HDHP)
  • Those who can be claimed as a dependent on another person's taxes
For 2020, the IRS allows an individual to contribute up to $3,550 and a family may contribute up to $7,100. These limits include the combined total of employer and employee contributions. Employees who are age 55 or older are allowed to contribute an additional $1,000 in catch-up contributions. Any remaining balance in the employee’s HSA will rollover and accumulate year to year.

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Required Signature

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By signing, I authorize to be covered under the terms of the plan I have chosen. *
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