Cardinal Insurance Form - Cardinal Services

PROVIDER: CARDINAL SERVICES, CARDINAL EMPLOYERS ORGANIZATION, PREFERRED EMPLOYER SOLUTIONS

Plan Summary Downloads

Dental Plan Summary & Document

Life Plan Summary

Vision Plan Summary & Document

Employer Name(Required)

Employer Benefit Contact Name(Required)

Employer Benefit Contact Phone Number(Required)

Employer Benefit Contact Email(Required)

Effective Date Employer would like to offer insurance to employees(Required)

The effective date would be 1st of the month after at least one month on Provider’s payroll PLUS one-month initial open enrollment period. See Provider for exceptions. Example: Date of hire: 1/15/2022 One-month on Provider’s payroll: 2/15/2022 One-month Initial open enrollment: 3/15/2022 Eligible Effective date: 4/1/2022

Complete the information for plans Employer would like to offer employees:

DENTAL PLAN

Premium Rates are subject to change annually. Refer to Dental Plan Information (include link to Dental Plan Summary & Document 2022)

Employer Contribution towards the monthly premium for EMPLOYEE(Required)

Enter Coverage Amount $

Employer Contribution towards the monthly premium for DEPENDENTS(Required)

Enter Coverage Amount $

VISION PLAN

Premium Rates are subject to change annually. Refer to Vision Plan Information (include link to Vision Plan Summary & Document 2022)

Employer Contribution towards the monthly premium for EMPLOYEE(Required)

Enter Coverage Amount $

Employer Contribution towards the monthly premium for DEPENDENTS(Required)

Enter Coverage Amount $

LIFE PLAN

Premium Rates are subject to change annually. Refer to Life Plan Information (include link to Life Plan Summary 2022)

Employer Contribution towards the monthly premium for EMPLOYEE(Required)

Enter Coverage Amount $

Employer Contribution towards the monthly premium for DEPENDENTS(Required)

Enter Coverage Amount $

Please note:

Employer to provide at least 30 days notification to Provider for any plan offering &/or Employer contribution changes.

Employment Status: Employer to notify Provider of employees’ employment status (Full time, Part time or Temporary/Seasonal), and changes to employment status in a timely manner. Employer is solely responsible for unpaid premiums, mid-term policy cancellations fees/funding, if any, or unpaid premiums that are uncollectable. Provider will invoice Employer for any unpaid fees or premium.

Premiums: Unless notified otherwise by Employer, employee premiums are withheld on a pre-tax basis (except where not allowed per IRS ruling). If pre-tax premiums are involved, employees may not make changes to their elections (which includes dropping their dependents’ coverage) outside of the annual plan renewal unless they experience an eligible Qualifying Event.

Inform Cardinal of any employees related to owners. Complete Online Form.