Louisville Urban League | 2023 Benefits Election Form 


All employees must complete this form.  Return no later than Friday, June 16, 2023.

To view a summary of all benefit options, click HERE.

Employee Name (PRINTED):  

Payroll Deductions are based on 24 pay periods

Medical Insurance 

The group medical insurance is changing. A benefit summary is attached. Please make an election below.  The deductions below are the cost per month (deductions will be divided over two (2) pay periods each month). 

Medical Election: Plan 1 - Anthem HSA Monthly

           

Medical Election: Plan 2 - Anthem PPO Monthly
        Employee  
           Employee
        Employee + Spouse
          Employee + Spouse
        Employee + Child(ren)  
          Employee + Child(ren) 
        Employee + Family
          Employee + Family

 

WAIVER  

 

Vision Insurance 

The vision plan benefit summary is outlined below.  The deductions below are the cost per month (deductions will be divided over two (2) pay periods each month).     

Vision Election:
         Employee
         Employee + Spouse
         Employee + Child(ren)  
        Employee +  Family

WAIVER  

 

Dental Insurance 

The dental plan benefit summary is outlined below. The deductions below are the cost per month (deductions will be divided over two (2) pay periods each month). 

Dental Election:
         Employee
         Employee/Spouse
         Employee/Child(ren)  
         Family

WAIVER   

 

Medical & Vision Enrollment Information (include yourself and dependents):

First Name

Last Name

Social Security #

Date of Birth

Sex (M/F)

Relationship

Electing Medical

Electing Vision

Electing Dental

 

I authorize The Louisville Urban League to deduct the above amounts. I understand that I am unable to change this authorization on pre-tax plans until the next open enrollment or unless I experience a qualifying event as defined by the Section 125 Cafeteria Benefits plan.  

Home Address (Street):    City:

State:    Zip Code: Phone:  

Leave this empty:

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