Kurtz Bros Central Ohio 2024 Open Enrollment

Submit your open enrollment elections by Monday, November 12, 2023.

•All plan changes are effective January 1, 2024.

•Your election will remain unchanged until open enrollment for 2025 unless you experience a qualifying event
–Marriage, Divorce, Baby, Adoption, Involuntary loss of coverage elsewhere, Changes in dependent eligibility

–Contact HR Department within 31 days of qualifying event

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* 1. Your Full Legal Name (First Name, Last Name):

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* 2. Your Phone Number:

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* 3. Your Email Address:

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* 4. List ALL Family Members You Want to Enroll/Waive in Medical/Rx, Dental and Vision (enter NA if not applicable)

Spouse

Child

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* 5. Please select your choice for Medical/Rx enrollment:

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* 6. Please select your choice for Dental enrollment:

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* 7. Select your choice for Vision Enrollment :

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* 8. FSA Enrollment (if you selected $1500, $2500 or $5000 plan), enter annual amount to be withheld (annual max TBD for 2024, 2023-$3050) - will be divided among 26 pays:

Waive

Amount

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* 9. HSA Enrollment (If you selected the $3200 HSA plan), enter annual amount to be withheld (annual max EE only $4150, Family $8300) - will be divided among 26 pays - can be changed at any time:

Waive

Amount

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* 10. Who is the beneficiary for your Company Paid Life Insurance? (Enter FULL name) - Minors not recommended.

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* 11. Do you wish to enroll in employee VOLUNTARY Life Insurance?

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* 12. Do you wish to enroll in spousal VOLUNTARY Life Insurance?

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* 13. Do you wish to enroll in Child(ren) VOLUNTARY Life Insurance?

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* 14. Do you wish to enroll in Long Term Disability Coverage? **Please note the min Annual Salary for each benefit. See open enrollment website for more details on the plan.

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* 15. Do you wish to enroll in Critical Illness Coverage?

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* 16. Do you wish to enroll in Accident Coverage?

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* 17. Do you wish to enroll in the Hospital Indemnity Protection Plan?

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* 18. Any additional comments/notes regarding your enrollment, please enter here.

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* 19. Sign/Type your name to confirm and acknowledge your enrollments