Health Plan 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.

Qualifying Effective Date & Reason for Enrolling

Qualifying effective date * +

Please select your reason for enrolling: *

General Information

Employer Name *

Employer Location or Church Code

Employee Last Name *

Employee First Name *

MI

Date of Birth * +

Social Security Number *

Home Phone

Work Phone

Cell Phone

Email Address *

Street Address *

City *

State *

Zip Code *

County

Gender: *

Marital Status: *

US Citizen/Citizen Resident: *

Benefit Election

Medical Benefits: *

Employee Only

Employee + Spouse

Employee + Child(ren)

Family

Coverage Type: *

Silver Premium Plan (Medical, HSA, Prescription, Dental, Vision, $30k Life Insurance, Long Term Disability)

Silver Standard Plan (Medical, HSA, Prescription, $30k Life Insurance)

Bronze Premium Plan (Medical, HSA, Prescription, Dental, Vision, $30k Life Insurance, Long Term Disability)

Bronze Standard Plan (Medical, HSA, Prescription, $30k Life Insurance)

Dependent Information

List spouse and/or children to be covered (eligible children are those under the age of 26)

1. Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Relationship

Disabled

2. Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Relationship

Disabled

3. Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Relationship

Disabled

4. Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Relationship

Disabled

5. Dependent Full Name (First, MI, Last)

SSN

Birth Date +

Gender

Relationship

Disabled

Are you or any of your dependents (including spouse) covered under another health plan or Medicare?

Yes

No

If yes, please explain:

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 optional. Please designate beneficiaries below:

1. Primary Beneficiary Name and Address

%

SSN

Relationship

2. Primary Beneficiary Name and Address

%

SSN

Relationship

3. Primary Beneficiary Name and Address

%

SSN

Relationship

Contingent(s)

1. Secondary Beneficiary Name and Address

%

SSN

Relationship

2. Secondary Beneficiary Name and Address

%

SSN

Relationship

3. Secondary Beneficiary Name and Address

%

SSN

Relationship

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. A brief explanation is available under the pop-up window in each category below.

Employee Voluntary Life Insurance: * 🛈

Yes

No

Spouse Voluntary Life Insurance: * 🛈

Yes

No

Child Voluntary Life Insurance: * 🛈

Yes

No

If yes, employee amount requested:

If yes, spouse amount requested:

If yes, child amount requested:

Evidence of Insurability
If you apply for voluntary life insurance outside of certain qualifying events (such as new hire, marriage or a birth), coverage is subject to approval based on evidence of insurability per medical testing. Therefore, it is advantageous to enroll when first joining the plan.

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 2024, the IRS allows an individual to contribute up to $4,150 and a family may contribute up to $8,300. 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.

I have read the above HSA section of this form and agree that it is my responsibility to be in compliance with IRS rules regarding my HSA. Alliance Benefits is not responsible for an ineligible employee participating in an HSA. Alliance Benefits must be notified if you are ineligible. Tax penalties may apply if the annual maximum contribution amounts are exceeded.

Subscribe to Blog

We recommend subscribing to the Alliance Benefits blog to receive important health and retirement plan information and updates throughout the year. Would you like to subscribe?

Yes

No

Required Signature

Employee's Signature Name *

Signature Date * +

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

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New Hire Enrollment	New Church to Plan	Employment Transfer
Rehire/Reinstatement	Loss of Coverage	Other (please describe) Other (please describe)