Summary of Benefits Worksheet
**This is NOT your enrollment form; you must enroll with a Benefits Administrator within 30 days of your hire date**
What should I bring to my one-on-one appointment with my Benefits Administrator?
1. This completed “Summary of Benefits Worksheet”
2. Retirement Packet (Received at orientation)
3. Dependent Eligibility Documentation (see attached)
Health Insurance
Plan:
□ Refuse
□ State Savings Health Plan
□ State Standard Health Plan
□ BlueChoice HMO
State Dental Plan
Basic Dental:
□ Refuse
□ Employee Only
□ Employee/Spouse
□ Employee/Child(ren)
□ Full Family
Coverage Level:
□ Employee Only
□ Employee/Spouse
□ Employee/Child(ren)
□ Full Family
Dental Plus:
□ Refuse
□ Yes
EyeMed State Vision
□ Refuse
□ Employee Only
□ Employee/Spouse
□ Employee/Child(ren)
□ Full Family
Optional Life
□ Refuse
□ Coverage Level $_________________
Dependent Life/Spouse
□ Refuse
□ Coverage Level $_________________
Dependent Life/Child
□ Refuse
□ Enroll
Supplemental Long Term Disability
□ Refuse
□ Plan One (90-day benefit waiting period)
□ Plan Two (180-day benefit waiting period)
MoneyPlu$ pretax premium feature - $.28 per month
□ Refuse
□ Yes
Retirement Plan
□ South Carolina Retirement Systems (SCRS)
□ Police Officer Retirement Systems (PORS)
□ ORP (Optional Retirement Plan)
□ TIAA-Cref
□ VALIC
□ MassMutual
□ MetLife
If married, the following information must be
completed: (Even if not enrolling in benefits)
Spouse’s Name: _________________________
(□ Male □ Female) (□ Husband □ Wife)
Date of Birth: ____/____/________
Social Security Number: ______-____-________
Enroll in: □ Health □ Dental □ Vision □ Life
Dependents:
Dependent Name: _________________________
Relationship: _________________________
□ Male □ Female
Date of Birth: ____/____/________
Social Security Number: ______-____-________
Enroll in: □ Health □ Dental □ Vision □ Life
Dependent Name: _________________________
Relationship: _________________________
□ Male □ Female
Date of Birth: ____/____/________
Social Security Number: ______-____-________
Enroll in: □ Health □ Dental □ Vision □ Life
Dependent Name: _________________________
Relationship: _________________________
□ Male □ Female
Date of Birth: ____/____/________
Social Security Number: ______-____-________
Enroll in: □ Health □ Dental □ Vision □ Life
Dependent Name: _________________________
Relationship: _________________________
□ Male □ Female
Date of Birth: ____/____/________
Social Security Number: ______-____-________
Enroll in: □ Health □ Dental □ Vision □ Life
Dependent Name: _________________________
Relationship: _________________________
□ Male □ Female
Date of Birth: ____/____/________
Social Security Number: ______-____-________
Enroll in: □ Health □ Dental □ Vision □ Life
Dependent Name: _________________________
Relationship: _________________________
□ Male □ Female
Date of Birth: ____/____/________
Social Security Number: ______-____-________
Enroll in: □ Health □ Dental □ Vision □ Life
Beneficiaries:
Beneficiary Name: _________________________
Relationship: _________________________
Date of Birth: ____/____/________
Social Security Number: ______-____-________
□ Basic Life – □ Primary □ Contingent
□ Optional Life – □ Primary □ Contingent
□ Retirement Funds – □ Primary □ Contingent
□ Incidental Death Benefit – Primary Only
Beneficiary Name: _________________________
Relationship: _________________________
Date of Birth: ____/____/________
Social Security Number: ______-____-________
□ Basic Life – □ Primary □ Contingent
□ Optional Life – □ Primary □ Contingent
□ Retirement Funds – □ Primary □ Contingent
□ Incidental Death Benefit – Primary Only
Beneficiary Name: _________________________
Relationship: _________________________
Date of Birth: ____/____/________
Social Security Number: ______-____-________
□ Basic Life – □ Primary □ Contingent
□ Optional Life – □ Primary □ Contingent
□ Retirement Funds – □ Primary □ Contingent
□ Incidental Death Benefit – Primary Only
Beneficiary Name: _________________________
Relationship: _________________________
Date of Birth: ____/____/________
Social Security Number: ______-____-________
□ Basic Life – □ Primary □ Contingent
□ Optional Life – □ Primary □ Contingent
□ Retirement Funds – □ Primary □ Contingent
□ Incidental Death Benefit – Primary Only
Beneficiary Name: _________________________
Relationship: _________________________
Date of Birth: ____/____/________
Social Security Number: ______-____-________
□ Basic Life – □ Primary □ Contingent
□ Optional Life – □ Primary □ Contingent
□ Retirement Funds – □ Primary □ Contingent
□ Incidental Death Benefit – Primary Only
Beneficiary Name: _________________________
Relationship: _________________________
Date of Birth: ____/____/________
Social Security Number: ______-____-________
□ Basic Life – □ Primary □ Contingent
□ Optional Life – □ Primary □ Contingent
□ Retirement Funds – □ Primary □ Contingent
□ Incidental Death Benefit – Primary Only
Most common forms of required Dependent
Eligibility Documentation:
Legal Spouse:
o Marriage License
– OR –
o Page 1 of Federal Tax Return
Natural Children:
o Copy of long form birth certificate showing the
subscriber as the parent
Step Child(ren):
o A copy of the long form birth certificate showing the
name of the natural parent
– PLUS –
o Proof that the natural parent and the subscriber are
married
Adopted Child(ren):
o A copy of the long form birth certificate showing the
subscriber as the parent
o Court document verifying completed adoption
o Letter of placement verifying the adoption is in
process
Foster Child(ren):
o Court order or other legal document placing the
child with the subscriber, who is a licensed foster
parent
Please refer to the attached Enrollment Eligibility
Documentation Worksheet for a complete list of
acceptable documents.