Nolan New Hire & QLE Enrollment Form 2023

NOLAN PAINTING HEALTHCARE ENROLLMENT FORM 2023

All information shared on this form is secure and private.
New Employee*

Click here if you are filling out this form because you are a new employee
Date of Hire*

MonthDayYear
Qualifying Life Event*

Click here if you are filling out this form due to a Qualifying Life Event, such as a marriage, birth, or loss of coverage
Please select the reason for your change*
Date of Qualifying Life Event*

MonthDayYear
This is the date that your event occurred
Employee Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Gender*
Marital Status*

SingleMarriedDivorcedWidow/widower
Social Security Number*
Primary Phone Number*

Area CodePhone Number
Email Address
MEDICAL INSURANCE
Please indicate your tobacco use*
All contribution rates are per pay period*
All contribution rates are per pay period*
IMPORTANT: The cancellation of Medical Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.
OTHER INSURANCE COVERAGE

Please provide your current medical insurance information below
Other Medical Insurance*

Insurance CarrierPlan ID/Group #
HEALTH SAVINGS ACCOUNT

Nolan Painting will contribute a dollar-for-dollar match up to $500 per year if you are enrolled as a single, or $1,000 per year if you are enrolled with dependents. For 2023, the maximum contribution amount for an individual is $3,850 and for a family is $7,750. Plus if you are age 55 or older, you can contribute an additional $1,000. These amounts include Nolan's contribution.
Per Pay HSA Contribution (52 pays per year)
Please leave blank if you are not participating.
DENTAL INSURANCE
All contribution rates are per pay period*
IMPORTANT: The cancellation of Dental Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.
EMPLOYEE DEPENDENT & SPOUSE INFORMATION

(Medical & Dental)
Spouse Information

Click here if you are electing medical or dental coverage for your spouse.
Child/Children Information

Click here if you are electing medical or dental coverage for your child/children.
Spouse Information*
First Name, Last Name, Middle Initial
Spouse's Gender*
Spouse's Date of Birth*

MonthDayYear
Spouse's Social Security Number*
Enroll Spouse in (check all that apply)*

MedicalDental
Please select the number of children who will be enrolled.
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDental
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDental
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDental
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDental
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDental
Child's Information*
First Name, Last Name, Middle Initial
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Social Security Number*
Enroll Child in (check all that apply)*

MedicalDental
AUTHORIZATION AND SIGNATURE

Please read carefully and then sign & date
- I understand that I cannot change any of these elections for medical, dental, and dependent coverage until the next open enrollment period, unless I have qualifying change in status.
- If I waived medical coverage, I certify that I have other medical coverage.
  Payroll Deduction/Pretax Premium/Billing Agreement: I authorize Nolan Painting and all its affiliates to deduct from my earnings the amount required to cover my share of the premium for these coverages.
- If I elect to participate in pretax medical and dental premiums, I authorize Nolan Painting and all its affiliates to reduce my taxable income by an amount equal to my medical and dental premiums.
- If I am being billed, I understand that failure to pay my premium(s) will result in cancellation of coverage.
- Waiver Agreement: After my initial enrollment period, I understand that in order to enroll in the future I may be required to provide evidence of insurability, and I may enroll in some plans only during open enrollment periods and/or be subject to pre-existing condition limitations.
- Release of Information: I understand that certain information collected by Nolan Painting, including some collected using this form, must be sent to the carriers of the plans in which I have enrolled. Nolan Painting and the insurance carriers will treat this information as confidential.
- 401(k) - I acknowledge receipt of the 401(k) Summary Plan Description provided to me by Nolan Painting Human Resources.
- I understand that I cannot change any of these elections for medical, dental, and dependent coverage until the next open enrollment period, unless I have qualifying change in status.
- If I waived medical coverage, I certify that I have other medical coverage.
  Payroll Deduction/Pretax Premium/Billing Agreement: I authorize Nolan Painting and all its affiliates to deduct from my earnings the amount required to cover my share of the premium for these coverages.
- If I elect to participate in pretax medical and dental premiums, I authorize Nolan Painting and all its affiliates to reduce my taxable income by an amount equal to my medical and dental premiums.
- If I am being billed, I understand that failure to pay my premium(s) will result in cancellation of coverage.
- Waiver Agreement: After my initial enrollment period, I understand that in order to enroll in the future I may be required to provide evidence of insurability, and I may enroll in some plans only during open enrollment periods and/or be subject to pre-existing condition limitations.
- Release of Information: I understand that certain information collected by Nolan Painting, including some collected using this form, must be sent to the carriers of the plans in which I have enrolled. Nolan Painting and the insurance carriers will treat this information as confidential.
Employee Signature*
Date*

MonthDayYear
Should be Empty:

NOLAN PAINTING HEALTHCARE ENROLLMENT FORM 2023

MEDICAL INSURANCE

OTHER INSURANCE COVERAGE

HEALTH SAVINGS ACCOUNT

DENTAL INSURANCE

EMPLOYEE DEPENDENT & SPOUSE INFORMATION

AUTHORIZATION AND SIGNATURE