Welcom
me to Fleeet Staff, Inc.! Th
his packett is a brieef overvieew regardding
the beenefits pllan offereed by Flleet Staff
ff. You w
will find informaation
regardiing the benefits offered, pricingg, eligibiility, andd additioonal
inform
mation to make a decision
d
regarding
r
g health ccare coveerage for you
and yo
our family
y.
ment is avvailable tto assist yyou with any
The Flleet Stafff Benefitss Departm
questio
ons or con
ncerns yo
ou might have
h
regaarding yoour benefiits, upon hire
or thro
oughout your em
mploymen
nt. The B
Benefits Departmeent provides
servicees to you that inclu
ude:
•
•
•
•
•
•
•
•
nterpretattion of beenefits
In
Enrollmen
E
nt assistan
nce
Claims
C
an
nalysis and
d help
In
nsurance billing isssues
Eligibility
E
y question
ns
Annual
A
op
pen enrolllment
Up
U to datee personall contact informatiion
COBRA
C
services
s
The Flleet Stafff Benefits Departm
ment is avvailable fr
from 8:000 AM to 55:00
PM ES
ST at the contact
c
in
nformatio
on below:
Fleeet Staff Benefits D
Departmennt
E Fultonn St.
8066 E.
Ada,, MI 493001
Phone: 866-4628
7786
Fax: 616-248-3277
Important Insurance Plan Details
Benefit Plans
The benefit plans offered consist of three plan options from Symetra Financial. Included in these
plans are dental, pharmaceutical, and pharmaceutical discount plans. All plans are underwritten
by Symetra Life Insurance Company.
Eligibility
•
•
•
•
•
To be eligible to participate in this plan, you must average 36 or more hours per week and
have worked for Fleet Staff for 90 days.
Eligible dependents include a spouse of an eligible Fleet Staff employee, and all children
of an eligible Fleet Staff employee up to the age of 26.
If you do not average at least 36 hours per week after your 90 day waiting period, you
will not be eligible to participate in this plan until the next annual open enrollment.
Unless you elect coverage under the Symetra Plan, CSS will automatically waive you
from the plan beginning on the 1st of the month following the 90-day eligibility period.
You may elect coverage during the annual open enrollment period, even if you waived
coverage at the time of hire.
If you elect coverage, your hours will be reviewed quarterly to determine if your
eligibility is continued.
Pricing
If you elect coverage, you will be responsible for 100% of the coverage premium. The
deductions will be taken on a weekly basis, beginning the first pay date before your effective
date. Fleet Staff offers an IRC (Internal Revenue Code) Section 125 Premium Conversion Plan.
This allows you to pay for your healthcare coverage on a before taxes basis. As a result, your net
take home pay will be higher than if contributions were deducted on an after tax basis.
The Symetra Plan pricing (per week) is listed below. Note: The medical coverage deduction will
be labeled as “Café” on paystubs.
Plan Level 1
Coverage Level Elected
Employee Only
Employee + One Dependent
Family (Employee + 2 or more Dependents)
Deduction Amount (per week)
$15.67
$29.23
$41.41
Plan Level 2
Coverage Level Elected
Employee Only
Employee + One Dependent
Family (Employee + 2 or more Dependents)
Deduction Amount (per week)
$25.74
$47.25
$66.08
Plan Level 3
Coverage Level Elected
Employee Only
Employee + One Dependent
Family (Employee + 2 or more Dependents)
Deduction Amount (per week)
$39.05
$73.43
$103.81
*Please refer to the following benefits summaries for more information regarding plan details.
Open Enrollment
Fleet Staff conducts open enrollment for employee changes every June. During this time, you
can elect coverage for yourself or dependent(s), waive, or edit coverage. Open enrollment
coverage changes are only available for those who have passed their 90 day eligibility period. If
you are still in your 90 day waiting period, you may edit your coverage choice to supersede your
election upon hire. These changes will be in place for your original effective date.
Fleet Staff Benefits Department
Please direct correspondence regarding your medical and prescription benefits to:
Keith Court, Benefits Manager
Fleet Staff, Inc.
8066 E. Fulton St.
Ada, MI 49301
P: (866) 462-7786
F: (616) 248-3277
E: [email protected]
Benefitts Enrollm
ment and Waiver F
Form
If you wish
w to elecct coveragee in a Fleett Staff bennefits plan, please filll out the
followin
ng informaation.
Choose One)
O
Plan Election (C
o Plan 1
o Plan 2
o Plan 3
Coveraage Levell (Choosee One)
o Employyee Only
o Employyee Plus One
O Depeendent*
o Family (Employyee Plus 2 or Moree Dependeents)*
Fill out thee following info
fo ONLY if you
ur coverage lev
vel selection inncludes dependdents.
Name
N
Birthdate
B
SSN
Spouse/Childd?
If you choose to WAIVE
E covera
age, pleasse select tthe follow
wing optiion:
o I have beeen given the oppoortunity tto enroll in the Flleet Stafff
group
g
inssurance policy.
p
I have
h
deciided not to elect tthis
coverage.
c
.
______
________
________
__
Employee Nam
me (Printed
d)
__________________________
Employyee Namee (Signatuure)
______
________
_____
SSN
______
____________
Date