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2025 BENEFITS ENROLLMENT

Effective Coverage: 9/1/2025-9/1/2026

Comprehensive Benefits to Support Your Health and Family Well-being

Types of Enrollment

Types of Enrollment

1. Employee Data (please print)

Marital Status

2. Health Plan

(a) Choose your Health Plan Option:
(b) Choose your Level of Coverage:
Deductions for Mira will be $28 per pay period for the employee only. Dependents, including children, spouses, and other family members, will incur an additional $28 per pay period for each dependent.
Deductions for Meridio per pay period will be based on the plan you choose and the dependents added.

3. Dental Plan

3. Dental Plan
Dental Insurance is covered through Delta Dental through Meridio. The deduction per pay period will be based on the plan you choose and the dependents added.

4. Vision Plan

4. Vision Plan
Vision Insurance is covered through VSP Vision through Meridio. The deduction per pay period will be based on the plan you choose and the dependents added.

5. Retirement Plan (pre-tax)

5. Retirement Plan (pre-tax)
Deductions for Icon will vary based on the amount you choose to save during the sign-up process.

6. Health Plan Information

7. Other Questions

Do you or your dependent(s) have additional health coverage?
If yes, provide the name of the carrier and address.
Do you or your dependent(s) have an additional retirement plan?
If yes, provide the name of the carrier and address.

8. Deductions

I Elect
8. Deductions

9. Commuter Assistant

Would you like to enroll in the company's Lyfy Program for transportation to and from work?
All ride costs will be deducted from your paycheck.

10. Enrollment Options

Please choose whether you would like to sign up for the health and/or retirement benefits below:
Retirement Benefits through Icon:

11. Signature

I certify below that I have completed this form to the best of my knowledge, and I understand the following:
• My coverage elections on this form cannot be revoked or modified during the year unless I have a qualifying change in status as defined by the IRS.
• Any pre-tax required contributions for the coverages I elect will reduce my pay.
• I acknowledge receiving a copy of the staff benefits handbook for my employee classification and reading the descriptions of the benefit plans in which I am enrolling. I also understand any limitations or restrictions on coverage or benefits under these benefit plans, as described in the staff benefits handbook.
I give permission to the health plan I select to obtain and/or examine my medical records (and/or those of my dependent(s)) from any health care practitioner or institution in which care is provided while a member, to the extent permitted by law; and I (we) understand the benefits and agree to the provisions as described in the plan document.
Signature