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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Signature Certificate
Document name: Louisville Urban League | 2023 Benefits Election Form 
lock iconUnique Document ID: 86749a7cac49899e00af431432c50c2cff9cf2a7
Timestamp Audit
May 15, 2020 1:38 pm ESTLouisville Urban League | 2023 Benefits Election Form  Uploaded by Lyndon Pryor - [email protected] IP 2600:1700:6cb2:8530:fcc0:7e7a:79a0:a084
May 15, 2020 3:53 pm ESTRhonda Mitchell - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:a414:5200:45f5:3930
May 15, 2020 3:56 pm ESTRhonda Mitchell - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 99.53.73.239
May 15, 2020 4:10 pm ESTRhonda Mitchell - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:ac0b:2b15:2b9c:abbc
May 13, 2021 3:09 pm ESTRhonda Mitchell - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 98.100.255.218
May 13, 2021 11:57 pm ESTRhonda Mitchell - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:d89f:4309:4b62:43ad
May 13, 2021 11:57 pm ESTAnita McGruder - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:d89f:4309:4b62:43ad
May 14, 2021 12:01 am ESTRhonda Mitchell - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:d89f:4309:4b62:43ad
May 14, 2021 12:02 am ESTAnita McGruder - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:d89f:4309:4b62:43ad
May 14, 2021 12:12 am ESTRhonda Mitchell - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:d89f:4309:4b62:43ad
May 14, 2021 12:12 am ESTAnita McGruder - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:d89f:4309:4b62:43ad
May 14, 2021 12:16 am ESTRhonda Mitchell - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:d89f:4309:4b62:43ad
May 14, 2021 12:16 am ESTAnita McGruder - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:d89f:4309:4b62:43ad
May 21, 2021 4:08 pm ESTRhonda Mitchell - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:e138:f226:9570:1dee
May 21, 2021 4:08 pm ESTAnita McGruder - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1702:1b21:2e50:e138:f226:9570:1dee
May 14, 2022 8:22 pm ESTDenise Dukes - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1700:6cb2:8530:f8cd:a289:7706:4e2f
May 14, 2022 8:22 pm ESTAnita McGruder - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1700:6cb2:8530:f8cd:a289:7706:4e2f
May 14, 2022 8:26 pm ESTDenise Dukes - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1700:6cb2:8530:f8cd:a289:7706:4e2f
May 14, 2022 8:26 pm ESTAnita McGruder - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1700:6cb2:8530:f8cd:a289:7706:4e2f
May 15, 2022 2:45 pm ESTDenise Dukes - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1700:6cb2:8530:e5d3:d8d7:1c79:8d9c
May 15, 2022 2:45 pm ESTAnita McGruder - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 2600:1700:6cb2:8530:e5d3:d8d7:1c79:8d9c
June 8, 2023 2:14 pm ESTDenise Dukes - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 98.100.255.218
June 8, 2023 2:14 pm ESTAnita McGruder - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 98.100.255.218
June 8, 2023 2:57 pm ESTDenise Dukes - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 69.135.110.187
June 8, 2023 2:57 pm ESTAnita McGruder - [email protected] added by Lyndon Pryor - [email protected] as a CC'd Recipient Ip: 69.135.110.187
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