| Candidate Information | | Title | Maintenance Manager Assistance Program | | Target Location | US-WI-Milwaukee |
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Click here or scroll down to respond to this candidateEmployee Information Please PRINT:SSN: - -Last Name: First Name:Birth Date:Hire Date:Address (street):Apt/Suite #:City:State:ZIP:Phone: -Email:Gender:Marital Status:Job Class: Crew Maintenance Manager2024 Enrollment / Change FormAll employees (FT or PT) are eligible to enroll in the following coverage: Reimbursement Assistance Program (RAP), Dental, Vision, Basic Term Life, Supplemental Life, Short and Long Term Disability.Covered Dependents: List all members to be added or voluntarily deleted (mark A for add or D for delete for each benefit).DentalVisionSupp. Dep. LifeRAPName (and address if not residing with employee)Date of BirthGenderRelationshipSocial Security NumberDisabledMedicare- eligibleADADADADYNYNADADADADYNYNADADADADYNYNReason for Enrollment:Newly Eligible (Coverage is effective the first of the month following a two month waiting period.)Annual Open Enrollment Period (Coverage is effective January 1st)Life Event: Date of Event _ _ / _ _ / _ _ _ _ (must choose event type below)Birth of Child/Adoption (attach proof of birth/adoption)Marriage (attach marriage license)Loss of other Health Coverage (attach proof of loss/certificate of coverage)2024 Bi-Weekly Benefit CostsDental:We offer two different dental plans, comprehensive and preventive.See next page for bi-weekly costs.Vision:Single: $2.54Employee + Spouse/ Domestic Partner: $5.08Employee + Child(ren): $5.08Family: $7.35RAP High Option:Single: $30.46Employee + Spouse/ Domestic Partner: $57.88Employee + Child(ren): $50.56Family: $77.06RAP Low Option:Single: $23.02Employee + Spouse/ Domestic Partner: $43.74Employee + Child(ren): $38.22Family: $58.24Are you eligible for Medicare? YesNoShort Team and Long Term DisabilityCost is based on current wage - See additional rate information on back.Supplemental Employee Term Life/AD&DSupplemental Spouse/Dependent Term LifeSupplemental Dependent Child(ren) Term LifeCost is based on current wage - See additional rate information on back.New hires can enroll following a 1 month waiting period. Coverage is effective the first of the month following the waiting period. Existing employees can enroll in any of the benefits by completing this form during Annual Open Enrollment. Employees experiencing a life event or loss of coverage can enroll within 31 days of the event.Dental, Vision and RAP Coverage Elections:Comprehensive Dental :Single ($16.77 bi-weekly)Employee + Spouse/ Domestic Partner ($35.18 bi-weekly)Employee + Child(ren) ($38.56 bi-weekly)Family ($75.42 bi-weekly)DECLINE COVERAGEPreventive Dental:Single ($12.44 bi-weekly)Employee + Spouse/ Domestic Partner ($26.11 bi-weekly)Employee + Child(ren) ($28.60 bi-weekly)Family ($55.94 bi-weekly)DECLINE COVERAGEVision:SingleEmployee + Spouse/ Domestic PartnerEmployee + Child(ren)FamilyDECLINE COVERAGEReimbursement Assistance Program (RAP):High Option Low OptionLow OptionDECLINE COVERAGEReimbursement Assistance Program (RAP) coverage type:Single Employee + Spouse/Domestic Partner Employee+Child(ren) FamilyEmployee + Child(ren) FamilyLife and Disability Coverage ElectionsSupplemental Employee Term Life/AD&D:1x annual earnings 2x 3x 4x 5x6x 7x 8x 9x 10x DeclineSupplemental Spouse/Dependent Term Life:(Supplemental Employee Term Life required)10,000 15,000 25,000 50,00075,000 100,000 DeclineSupplemental Dependent Child(ren) Term Life:(Supplemental Employee Term Life required)EnrollDeclineSTD500:EnrollDeclineSTD1000:EnrollDeclineLong-Term Disability:EnrollDeclineBeneficiary InformationThe person(s) you name below will receive any Basic Term Life and Supplemental Term Life benefits that are payable at your death. If you name more than one beneficiary, they will share equally in any death benefit unless you specifically designate otherwise. Any previous beneficiary designation is automatically revoked.Name (First, Last)Beneficiary AddressRelationshipAllocationPercentPrimaryContingent%PrimaryContingent%PrimaryContingent%Employee SignatureSignature: Date:Return completed enrollment form to your manager and ask them to scan it to Shawn Senn in Human Resources. You may also email your enrollment form to:Shawn.senn@courtesycorporation.com.You can visit www.McDRMHCBenefits.com at any time during the year to get more details about your benefits and enrollment. The site is mobile-friendly and no password is needed! You may also contact Shawn Senn at PHONE NUMBER AVAILABLEGet Started: McDonalds Licensees Online Enrollment InstructionsGo to McDRMHCBenefits.com the site is your one-stop for all benefits information! When youre ready to enroll for 2024 benefits, simply click Plan Participants then click the link to the Participant Enrollment Site, where you will need to log in. Need help logging in? Call the Participant Support Line at PHONE NUMBER AVAILABLEThis year, the Plan will use a newly enhanced enrollment website, so everyone must create a new account to register.1.Under New Users, click Get Started.2.You will be prompted to enter the last 4 of your SSN, Last Name, Date of Birth, Country, Zip Code, and complete a reCAPTCHA security check.3.You will then select the email on file or phone number on file to receive your verification code and set up Multi-Factor Authentication.4.You will then select your username and create your password.If you do not have an email on file, you will be prompted to enter the last 4 of your SSN, Last Name, Date of Birth, Country, Zip Code, and complete a reCAPTCHA security check. You will then enter your email and be sent a verification code. You will then select your username and create your password.If your email address on file is incorrect, you will be prompted to enter the last 4 of your SSN, Last Name, Date of Birth, Country, Zip Code, and complete a reCAPTCHA security check. When prompted to send a code to the email or phone number on file, click I dont have access to these anymore. Help me! link. You will then be prompted to answer 3 to 4 security questions to verify your identity. You will then enter your email, and be sent a verification code. You will then select your username and create your password.Enroll For 2024 BenefitsAfter logging into the site, you will have the opportunity to review all your benefits information for the 2024 plan year. If youre enrolling a new dependent, youll need to provide verification that the dependent is eligible (Your Federal 1040 or State income tax return) to Mercer. If you dont submit documentation, medical coverage for newly-added spouses or dependents will be terminated.After reviewing your available 2024 options, log in and click Go to enroll. You will be guided through several screens where you will elect the benefits you wish to be enrolled in for the 2024 plan year.IMPORTANT: Your elections will not be recorded and saved until you complete all the screen prompts and reach the Confirmation page. Dont forget to write down your confirmation number and keep it for your records.You can return and make additional changes to your elections at any time before December 14, 2023. Each time you make a change, you will receive a new confirmation number. Remember to write down your confirmation number each time. Only the last confirmation in the Annual Enrollment period will be processed.Dont Forget! After Youve EnrolledYou can access and print a copy of your 2024 confirmation statement online. You will also receive a confirmation statement in the mail at home. When you receive your statement, check it carefully to make sure everything looks accurate. If there are any issues, contact your employer or the Participant Support Line at PHONE NUMBER AVAILABLE right away.If you are enrolling a spouse or dependent in medical coverage, dont forget to submit acceptable supporting documentation to finalize your enrollment request.Reimbursement Assistance Program (RAP) You have two options for the RAP: A High Option (offering higher reimbursement amounts but costing more per paycheck) and a Low Option (offering lower reimbursement amounts for a lower paycheck cost). For Questions or Claim Forms, contact the RAP Support Center at PHONE NUMBER AVAILABLEReimbursement Assistance ProgramThe fixed dollar amount the RAP pays toward your medical billType of CareHigh OptionLow OptionOutpatient Medical BenefitOutpatient Medical Benefit Maximum (all outpatient benefits are subject to outpatient maximum)$1,500$1,000Physician Office Visit and Diagnostic (Lab) (per day)$100Diagnostic (X-ray) (per day)$250Ambulance Services (per day)$350Emergency Room Benefit - Sickness (per day)$125Emergency Room Benefit - Accident (per day)$500Surgery (per day)$600Anesthesiology (per day)$120Inpatient Hospital Benefit: requires 24-hour minimum staySurgery (per day)$1,500$1,000Anesthesiology (per day)$300$200Standard Care (per day, up to a 30-day calendar maximum per year)$600$350Intensive Care (per day, up to a 15-day calendar maximum per year, and paid in addition to standard care benefit)$600$350Skilled Nursing (per day, up to a 60-day calendar maximum per year, and payable for stays in a nursing facility after a hospital stay)$100Wellness CareWellness Care (1 per year)$100Prescription Drugs: unlike with medical care, you pay a flat copay for each prescription under the RAPAnnual Maximum (maximum benefit the RAP will pay over a calendar year)$600Generic Copay (the most you pay out-of-pocket for each generic prescription)You pay up to $10Brand Copay (the most you pay out-of-pocket for each name-brand prescription)You pay up to $50Life and Accident InsuranceSupplemental Term Life Insurance Benefits. Supplemental Life is provided by Securian Fnancial (lifebenefits.com). If you are newly eligible to the plan, you can add up to 10 times your annual salary (up to $500,000 of coverage) without providing evidence of insurability. Existing employees who chose to elect supplemental term life insurance must provide evidence of insurability (proof of your good health) whenever you increase your supplemental term life benefit by more than one level during Annual Enrollment. Election of one times salary or increase by one times salary is guaranteed without evidence of insurability during Annual Enrollment.Dependent Supplemental Term Life Insurance can be added for eligible dependents. Dependent coverage amount cannot exceed your total life insurance coverage amount. You must be enrolled in employee Supplemental term life to be eligible to enroll in dependent supplemental term life.Supplemental Term Life Insurance is guaranteed issue for all spouse/domestic partner coverage up to $25,000 if elected within 31 days of initial eligibility. Supplemental term life insurance is always guaranteed issue for all child coverage.Type of CoverageAmount of CoverageSpouse/domestic partner (may not exceed 100% of your total basic and supplemental amount)$10,000$15,000$25,000$50,000$75,000$100,000Child (each)$10,000Short-Term and Long-Term Disability InsuranceDisability coverage is available to help protect you against loss of income in the event of an extended illness or injury. Coverages are now issued by The Hartford (replacing Lincoln Financial Group) www.thehartford.com.Short-Term Disability (STD): This coverage pays a benefit beginning on the 15th day of a sickness or injury.There are two Short-Term Disability options:STD 500: Pays 50% of your basic earnings, up to $500 per weekSTD 1000: Pays 66-2/3% of your basic earnings, up to $1000 per weekLong-Term Disability (LTD): This coverage pays benefits after 180 days of consecutive disability. The monthly benefit is 60% of your of your basic monthly income. If you remain disabled, benefits generally continue until your normal retirement age as defined under the Social Security Act.All disability claims are subject to approval by The Hartford. Employees who newly elect disability coverage are subject to the pre-existing condition limitation. A pre-existing condition is a condition resulting from an injury or sickness for which the employee is diagnosed or treated within three months prior to the employees effective date of coverage.Dental InsuranceParticipants have a choice between the Preventative Plan and the Comprehensive Plan. The Preventative Plan offers a lower premium cost, a higher deductible, and does not cover orthodontia. The Comprehensive Plan has a higher premium cost, a lower deductible, and does include orthodontia coverage. Participants in either plan can go to any licensed dentist, and benefits are the same whether you use a network or non-network provider. If you go to a non-network dentist, your benefit level is the same, but your out-of-pocket expenses may be higher.Participants must actively elect coverage during 2024 Annual Enrollment to participate in the new Preventive Plan. Participants enrolled in dental coverage in 2023 who do not make an active dental plan election during Annual Enrollment will default to coverage under the new Comprehensive Plan.Comprehensive Dental Plan BenefitsServiceDeductiblePlan PaysMaximum BenefitPreventive CareNone100% of maximum allowed fees$2000 annual maximum for covered services (excluding orthodontia)Primary Care$50 per person per calendar year (covers both Primary and Major services)90% of maximum allowed feesMajor Care50% of maximum allowed feesOrthodonticsNone50% of maximum allowed fees$2000 per person lifetime maximumPreventive Dental Plan BenefitsServiceDeductiblePlan PaysMaximum BenefitPreventive CareNone100% of maximum allowed fees$1000 annual maximum for covered servicesPrimary Care$100 per person per calendar year (covers both Primary and Major services)80% of maximum allowed feesMajor Care50% of maximum allowed feesOrthodonticsNot coveredN/AN/ATo locate a Delta Dental PPO or Delta Dental Premier provider, visit www.deltadentalil.com or call customer service at PHONE NUMBER AVAILABLE Dentists in the Delta Dental PPO and Delta Dental Premier networks will have lower fees.Vision InsuranceBenefits for the vision care plan are provided through EyeMed. EyeMeds network includes private doctors as well as major chains including LensCrafters, Shopko Optical, most Pearle Vision locations, Target, and more.Summary of Vision Plan BenefitsServices and MaterialsIn-NetworkOut-of-NetworkMaximum BenefitsEye Exam for eyeglasses once per calendar yearCovered in FullUp to $60Standard uncoated plastic lenses once per calendar year:Single visionBifocal VisionTrifocal visionStandard ProgressivePremium ProgressiveCovered in fullCovered in fullCovered in full$55 copaymentContact EyeMedUp to $30Up to $50Up to $65Up to $50Up to $50Lens optionsContact EyeMed$5 reimbursementFrames once per calendar year$175 maximum benefitUp to $55Standard contact lens fitting and follow-upMember pays up to $40Not coveredContact lenses once per calendar year in lieu of spectacle lenses (materials only, conventional/disposable)$175 maximum benefitUp to $75Contact lenses once per calendar year when medically necessary (materials only)Paid in fullUp to $130Additional pairs (unlimited) of eyeglasses/contact lenses40% discount off complete pair eyeglass purchasesNot coveredFor more information or to find a participating EyeMed provider, call 1-866-723-0514, visit www.eyemed.com, or download the EyeMed app from the App Store or Google Play. Choose Select from the network options. |
